Barriers and Facilitators to Teledermatology and Tele-Eye Care in Department of Veterans Affairs Provider Settings: Qualitative Content Analysis

BACKGROUND

Veterans Affairs health care systems have been early adopters of asynchronous telemedicine to provide access to timely and high-quality specialty care services in primary care settings for veterans living in rural areas. Scant research has examined how to expand primary care team members' engagement in telespecialty care.

OBJECTIVE

This qualitative study aimed to explore implementation process barriers and facilitators to using asynchronous telespecialty care (teledermatology and tele-eye care services).

METHODS

In total, 30 participants including primary care providers, nurses, telehealth clinical technicians, medical and program support assistants, and administrators from 2 community-based outpatient clinics were interviewed. Semistructured interviews were conducted using an interview guide, digitally recorded, and transcribed. Interview transcripts were analyzed using a qualitative content analysis summative approach. Two coders reviewed transcripts independently. Discrepancies were resolved by consensus discussion.

RESULTS

In total, 3 themes were identified from participants' experiences: positive perception of telespecialty care, concerns and challenges of implementation, and suggestions for service refinement. Participants voiced that the telemedicine visits saved commute and waiting times and provided veterans in rural areas more access to timely medical care. The mentioned concerns were technical challenges and equipment failure, staffing shortages to cover both in-person and telehealth visit needs, overbooked schedules leading to delayed referrals, the need for a more standardized operation protocol, and more hands-on training with formative feedback among supporting staff. Participants also faced challenges with appointment cancellations and struggled to find ways to efficiently manage both telehealth and in-person visits to streamline patient flow. Nonetheless, most participants feel motivated and confident in implementing telespecialty care going forward.

CONCLUSIONS

This study provided important insights into the positive perceptions and ongoing challenges in telespecialty care implementation. Feedback from primary care teams is needed to improve telespecialty care service delivery for rural veterans.

Telemedicine-based approach to caring for patients with inherited retinal diseases: patient satisfaction and diagnostic testing completion rates

BACKGROUND

During the COVID-19 pandemic, the Emory Ophthalmic Genetics Service (EOGS) adopted a hybrid telehealth-based care model, with patients undergoing a tailored panel of ancillary tests in addition to a video telehealth encounter with the EOGS physician. This study evaluates patient satisfaction with this model and effectiveness of these encounters in producing a clinical and genetic diagnosis.

MATERIALS AND METHODS

A trained interviewer administered a 14-question validated patient satisfaction survey to eligible subjects between October 2020 and April 2021. A mean "favorability index" for patient satisfaction was calculated (maximum score = 5). Rates of ancillary testing, completion of genetic testing, and diagnostic accuracy were also assessed, and compared to results from a control group of EOGS patients that underwent in-person visits.

RESULTS

Twenty-one of 33 eligible patients completed the survey. Nine (42.9%) were female, with mean (± SD) age 51.3 ± 13.6 years. The control group was comprised of 49 subjects, predominantly female (71.4%), with mean age 51.5 ± 15.2 years. The mean (range) favorability index was 4.3 (3.1-5.0). Rates of ancillary testing were lower for the telemedicine group vs. the control group: 38.1% vs. 85.7% (p < .001) for electrophysiology; 42.9% vs. 71.4% (p = .03) for perimetry; and 81.0% vs. 95.9% (p = .04) for fundus imaging. Two (11.1%) and 1 (2.8%) (p = .21) subjects in the telehealth and control groups, respectively, did not complete recommended genetic testing. The clinical diagnosis was compatible with the genetic diagnosis in all subjects.

CONCLUSIONS

Our results suggest high patient satisfaction and diagnostic accuracy with a hybrid telemedicine-based approach for IRD care, despite lower rates of ancillary testing and no in-person examination.

Exporting Diabetic Retinopathy Images from VA VistA Imaging for Research

The US Department of Veterans Affairs has been acquiring store and forward digital diabetic retinopathy surveillance retinal fundus images for remote reading since 2007. There are 900+ retinal cameras at 756 acquisition sites. These images are manually read remotely at 134 sites. A total of 2.1 million studies have been performed in the teleretinal imaging program. The human workload for reading images is rapidly growing. It would be ideal to develop an automated computer algorithm that detects multiple eye diseases as this would help standardize interpretations and improve efficiency of the image readers. Deep learning algorithms for detection of diabetic retinopathy in retinal fundus photographs have been developed and there are needs for additional image data to validate this work. To further this research, the Atlanta VA Health Care System (VAHCS) has extracted 112,000 DICOM diabetic retinopathy surveillance images (13,000 studies) that can be subsequently used for the validation of automated algorithms. An extensive amount of associated clinical information was added to the DICOM header of each exported image to facilitate correlation of the image with the patient's medical condition. The clinical information was saved as a JSON object and stored in a single Unlimited Text (VR = UT) DICOM data element. This paper describes the methodology used for this project and the results of applying this methodology.

Eye Care Productivity and Access in the Veterans Affairs Health Care System

OBJECTIVES

Eye care in the Veterans Affairs Health Care System is challenged with increasing demand and higher prevalence of patients with complex ocular conditions. Understanding factors that impact eye care productivity and access is necessary for appropriate allocation of resources. The purpose of this study was to determine the impact of various eye clinic personnel on eye care provider productivity and patient access.

METHODS

Utilizing data from the Veterans Health Administration National Data Warehouse, workload and level of staffing were analyzed. Trends in the data were analyzed using descriptive and regression analyses employing both linear and curve fitting modeling methods.

RESULTS

There was a significant positive correlation between ophthalmology technicians and ophthalmologist productivity (p < 0.001), number of unique patients seen per year per provider (p = 0.047), and total yearly number of office visits per provider (p < 0.001). Similarly, there was a significant positive correlation between number of ophthalmology residents and productivity (p = 0.046) and number of clinic visits per provider (p < 0.001) but not the number of unique patients seen. Positive correlation was found between optometry technicians and the number of unique patients' seen by optometrists (p = 0.041) and total number of clinic visits per provider (p < 0.001) but not optometrist productivity. No significant correlations were present for nurses, nurse practitioners, physician assistants, or clerical staff.

CONCLUSION

Eye care technicians provide a cost-effective multiplier effect for provider productivity, especially in ophthalmology clinics, allowing significant increases in total clinic visits and number of unique patients seen per year.

Variant prostate carcinoma and elevated serum CA-125

INTRODUCTION

About 10% of tumors derived from nongynecologic, noncoelomic tissues react with the OC125 antibody. Some patients with advanced prostate cancer were found to have elevated serum CA-125 level.

MATERIALS AND METHODS

We examined the clinical history of 11 patients with castration resistant prostate cancer and an elevated serum CA-125 level. Pathological review and immunohistochemical staining were performed on tumors from eight of these patients.

RESULTS

Patients with advanced prostate cancer and an elevated serum CA-125 level responded to androgen ablative therapy (median duration, 27 months). They were predisposed to develop persistent or recurrent urinary symptoms and visceral metastases. Eight of 11 patients had a low or undetectable serum prostate-specific antigen level (≤ 4 ng/mL) or an elevated serum carcinoembryonic antigen level (> 6 ng/mL). In 3 of 7 patients whose specimens were available for further review, the tumors contained histologic features compatible with a diagnosis of ductal or endometrioid adenocarcinoma of the prostate.

CONCLUSIONS

Patients with prostate cancer and an elevated serum CA-125 level have unique clinical and pathologic characteristics. Some of these patients possess tumors compatible with a subtype of prostate cancer known as ductal adenocarcinoma. Additional studies need to be performed to elucidate the biologic basis of the various subtypes of prostate cancer.

Medical education in the public versus the private setting: a qualitative study of medical students' attitudes

Public hospitals serve as primary training sites for medical students. Public patients may therefore bear a disproportionate burden of medical student education. The purpose of this study was to critically examine the ethics of medical education in the public setting. Attitudes of first- and fourth-year students towards the role of public patients in medical education were elicited in focus groups. Inductive qualitative analysis was utilized to organize data into conceptual groups, which were then analyzed within an ethical framework. All patients have an equal obligation to participate in medical education. Students identified modifying factors that could affect a patient's obligation to educate future physicians. Available data highlight a concern that public teaching hospitals may provide a lower quality of care. If true, then the public teaching setting is creating an unfair burden upon that patient population who would then have a weakened obligation to participate in medical education.

Prostate carcinoma with testicular or penile metastases. Clinical, pathologic, and immunohistochemical features

BACKGROUND

Despite the proximity, prostate carcinoma seldom metastasizes to the penis or testis.

METHODS

In the current study, the authors retrospectively examined the clinical history of 12 patients with prostate carcinoma and testicular or penile metastases. Pathologic review and immunohistochemical staining were performed on tumors from eight of these patients.

RESULTS

Patients with prostate carcinoma and testicular or penile metastasis responded to androgen ablative therapy (median duration, 33 months). They were predisposed to developing persistent or recurrent urinary symptoms and visceral metastases. Six of 9 evaluable patients had elevated serum carcinoembryonic antigen levels (> 6 ng/mL), whereas 2 of 10 patients had low or undetectable serum prostate specific antigen levels (< 4 ng/mL). In seven of the eight patients for whom specimens were available, the tumors were found to contain histologic features that were compatible with a diagnosis of ductal or endometrioid adenocarcinoma of the prostate.

CONCLUSIONS

Patients with prostate carcinoma and testicular or penile metastases have unique clinical and pathologic characteristics. Many of these patients' tumors are compatible with a subtype of prostate carcinoma known as ductal adenocarcinoma. Further studies need to be performed to elucidate the biologic basis of the various histologic subtypes of prostate carcinoma.

Mononuclear cell proliferation and hyperplasia during Wallerian degeneration in the visual system of the goldfish in the presence or absence of regenerating optic axons

Patterns of proliferation and changes in non-neuronal cell number in the visual system of the goldfish have been quantitatively examined during optic axon regeneration after an optic nerve crush (ONC). In addition, in order to examine the effect of the regenerating axons on cellular responses in the visual pathways, we did a similar analysis of animals with the right eye removed (ER). Finally, we used double labeling protocols to demonstrate that the proliferating cells that we were counting were mostly phagocytic cells of the mononuclear lineage. In animals with an ONC, we observed an early burst of proliferation that peaked between 7 and 14 days after surgery in all parts of the visual system. In the optic tract, there was also a secondary rise that peaked at 21 days. Levels of proliferation returned to normal by 32 days postoperative in the tract and tectum, while they remained somewhat elevated in the optic nerve for at least 93 days. The total number of non-neuronal cells in the visual paths also rose to peak values between 7 and 14 days after ONC surgery. In the optic tract and tectum, the values fell rapidly after this time, while in the optic nerve, there was a secondary peak at 32 days after which values remained elevated for the duration of the experiment. As compared to animals with an ONC, enucleation resulted in elevated proliferation and hyperplasia at early postoperative intervals. However, because these differences occurred when axons had not yet regenerated into the affected structures, these data do not provide strong evidence for a direct effect of regenerating optic axons on the early cellular responses during Wallerian degeneration in the goldfish. In addition, in the tectum, there was an early increment in cell number that was not associated with elevated levels of proliferation. We believe that this increment represents immigration of resident microglia from other regions of the brain.