Implementation of a pediatric telemedicine and medication delivery service in a resource-limited setting: A pilot study for clinical safety and feasibility

OBJECTIVE

Determine the clinical safety and feasibility of implementing a telemedicine and medication delivery service (TMDS) to address gaps in nighttime access to healthcare for children in low-resource settings.

STUDY DESIGN

We implemented a TMDS called 'MotoMeds' in Haiti as a prospective cohort study. A parent/guardian of a sick child ≤10 years contacted the call center (6pm-5am). A nurse provider used decision support tools to triage cases (mild, moderate, severe). Severe cases were referred to emergency care. For non-severe cases, providers gathered clinical findings to generate an assessment and plan. For cases within the delivery zone, a provider and driver were dispatched and the provider performed a paired in-person exam as a reference standard for the call center assessment. Families received a follow-up call at 10 days. Data were analyzed for clinical safety and feasibility.

RESULTS

A total of 391 cases were enrolled from September 9, 2019, to January 19, 2021. Most cases were not severe (92%; 361); household visits were completed for 89% (347) of these cases. Among the 30 severe cases, 67% (20) sought referred care. Respiratory problems were most common (63%; 246). At 10-days, 95% (329) of parents reported their child "improved" or "recovered". Overall 99% (344) rated the TMDS as "good" or "great". The median phone consultation time was 20 minutes, time to household arrival was 73 minutes, and total time was 114 minutes/case.

CONCLUSION

The TMDS was a feasible healthcare delivery model. Although many cases were likely self-limiting, the TMDS was associated with high rates of reported improvement in clinical status at 10 days.

A Nighttime Telemedicine and Medication Delivery Service to Avert Pediatric Emergencies in Haiti: An Exploratory Cost-Effectiveness Analysis

We sought to compare the costs of a nighttime pediatric telemedicine and medication delivery service per disability-adjusted life year (DALY) averted to the costs of current hospital emergency care per DALY averted from a societal perspective. We studied a nighttime pediatric telemedicine and medication delivery service and hospital emergency care in a semi-urban and rural region of Haiti. Costs of the two services were enumerated to represent the financial investments of both providers and patients. DALYs averted were calculated to represent the "years lives lost" and "years lost to disability" from diarrheal, respiratory, and skin (bacterial and scabies etiologies) disease among children from 0 to 9 years old. The incremental cost-effectiveness ratio was estimated and compared with the per capita gross domestic product (GDP) of Haiti ($1,177). Cost-effectiveness was defined as an incremental cost-effectiveness ratio less than three times the per capita GDP of Haiti ($3,531). The total costs of the nighttime telemedicine and medication delivery service and hospital emergency care to society were $317,898 per year and $89,392 per year, respectively. The DALYs averted by the service and hospital emergency care were 199.76 and 22.37, respectively. Correspondingly, the incremental cost-effectiveness ratio is estimated at $1,288 signifying that the service costs an additional $1,288 to avert one additional DALY. A scaled nighttime pediatric telemedicine and medication delivery service is likely a cost-effective alternative to hospital emergency care for pre-emergency pediatric conditions in Haiti, and possibly in similar lower-middle-income countries.

Hearing Impairment and Undiagnosed Disease: The Potential Role of Clinical Recommendations

PURPOSE

The objective of this study was to use cross-sectional, nationally representative data to examine the relationship between self-reported hearing impairment and undetected diabetes, hypertension, hypercholesterolemia, and chronic kidney disease.

METHOD

We analyzed the National Health and Nutrition Examination Survey for the years 2007-2012 for individuals 40 years of age and older without previously diagnosed cardiovascular disease. Analyses were conducted examining hearing impairment and undiagnosed disease.

RESULTS

The unweighted sample size was 9,786, representing 123,444,066 Americans. Hearing impairment was reported in 10.2% of the individuals. In unadjusted analyses, there was no significant difference between adults with hearing impairment and adults with typical hearing for undiagnosed diabetes, hypertension, or hypercholesterolemia. A higher proportion of adults with hearing impairment than adults with typical hearing had undiagnosed chronic kidney disease (20.1% vs. 10.7%; p = .0001). In models adjusting for demographics and health care utilization, hearing impairment was associated with a higher likelihood of having undiagnosed chronic kidney disease (odds ratio = 1.53, 95% CI [1.23, 1.91]).

CONCLUSIONS

Individuals with hearing impairment are more likely to have undiagnosed chronic kidney disease. Hearing impairment may affect disclosure of important signs and symptoms as well as the comprehension of medical conversations for chronic disease management. General practitioners can play a critical role in improving medical communication by responding with sensitivity to the signs of hearing impairment in their patients.

A longitudinal analysis of the effect of mass drug administration on acute inflammatory episodes and disease progression in lymphedema patients in Leogane, Haiti

We conducted a longitudinal analysis of 117 lymphedema patients in a filariasis-endemic area of Haiti during 1995-2008. No difference in lymphedema progression between those who received or did not receive mass drug administration (MDA) was found on measures of foot (P = 0.24), ankle (P = 0.87), or leg (P = 0.46) circumference; leg volume displacement (P = 0.09), lymphedema stage (P = 0.93), or frequency of adenolymphangitis (ADL) episodes (P = 0.57). Rates of ADL per year were greater after initiation of MDA among both groups (P < 0.01). Nevertheless, patients who received MDA reported improvement in four areas of lymphedema-related quality of life (P ≤ 0.01). Decreases in foot and ankle circumference and ADL episodes were observed during the 1995-1998 lymphedema management study (P ≤ 0.01). This study represents the first longitudinal, quantitative, leg-specific analysis examining the clinical effect of diethylcarbamazine on lymphedema progression and ADL episodes.

Malaria prevention knowledge, attitudes, and practices (KAP) among international flying pilots and flight attendants of a US commercial airline

BACKGROUND

In 2010, malaria caused approximately 216 million infections in people and 655,000 deaths. In the United States, imported malaria cases occur every year, primarily in returning travelers and immigrants from endemic countries. In 2010, five Plasmodium falciparum malaria cases occurred among crew members of one US commercial airline company (Airline A). This investigation aimed to assess the malaria prevention knowledge, attitudes, and practices (KAP) of Airline A crew members to provide information for potential interventions.

METHODS

The web link to a self-administered on-line survey was distributed by internal company communications to Airline A pilots and flight attendants (FA) eligible for international travel. The survey collected demographic information as well as occupation, work history, and malaria prevention education.

RESULTS

Of approximately 7,000 nonrandomly selected crew members, 220 FA and 217 pilots completed the survey (6%). Respondents correctly identified antimalarial medication (91% FA, 95% pilots) and insect repellents (96% FA, 96% pilots) as effective preventive measures. While in malaria-intense destinations, few FA and less than half of pilots always took antimalarial medication (4% FA, 40% pilots) yet many often spent greater than 30 minutes outdoors after sundown (71% FA, 66% pilots). Less than half in both groups always used insect repellents (46% FA, 47% pilots). Many respondents were unaware of how to get antimalarial medications (52% FA, 30% pilots) and were concerned about their side effects (61% FA, 31% pilots).

CONCLUSION

Overall, FA and pilots demonstrated good knowledge of malaria prevention, but many performed risky activities while practicing only some recommended malaria preventive measures. Malaria prevention education should focus on advance notification if traveling to a malaria-endemic area, how to easily obtain antimalarial medications, and the importance of practicing all recommended preventive measures.