Journal of Telemedicine and Telecare最新文献

IntroductionDespite its reach, very limited evidence exists on the effectiveness of real-time video counselling for smoking cessation (e.g. via Skype). This study compared the effectiveness of real-time video counselling for smoking cessation to (a) telephone counselling; and (b) a control among rural and remote residents.MethodsBetween 25 May 2017 and 3 March 2020, a three-arm, parallel group, randomised trial, randomised 1244 rural and remote residents from New South Wales, Australia who smoked tobacco to: video counselling (4-6 video sessions); telephone counselling (4-6 telephone calls); or a control (printed materials). The primary outcome was 7-day point prevalence abstinence at 13 months post-baseline. Secondary outcomes were point prevalence abstinence at 4 months and 7-months post-baseline, prolonged abstinence, quit attempts, anxiety and depression.ResultsFor the primary outcome of 7-day point prevalence abstinence at 13 months post-baseline, there was no significant difference between video counselling and telephone counselling (14.6% vs 13.3%; (OR = 1.11, 95% CI (0.75-1.64), P = 0.61) or video counselling and control (14.6% vs 13.9%; (OR = 1.06, 95% CI (0.71-1.57), P = 0.77). For secondary outcomes at 4 months post-baseline, the video counselling group had significantly higher odds than the control of 7-day point prevalence abstinence (14.3% vs 8.2%; OR = 1.88, 95% CI (1.20-2.95), P = 0.006) and 3-month prolonged abstinence (4.9% vs 2.2%; OR = 2.28, 95% CI (1.03-5.07), P = 0.04). There were no significant differences for other secondary outcomes.DiscussionVideo counselling increased smoking cessation in the short-term compared to a control although strategies to improve its long-term effectiveness are needed.Trial registrationAustralian New Zealand Clinical Trials Registry, https://www.anzctr.org.au ACTRN12617000514303.

BackgroundThe rising incidence of melanoma and the high number of benign lesions excised due to diagnostic uncertainty highlight the need for effective patient triage. This study assesses the safety and accuracy of teledermoscopic triage on a high-prevalence case set with pre-triaged, challenging, melanoma-suspicious lesions.MethodsFive dermatologists independently reviewed 250 retrospectively extracted patient cases. Teledermoscopy assessments were simulated for panels of 1, 2, 3 and 5 assessors using two distinct consensus strategies, Caution Protocol and Majority Vote, and the sensitivity and specificity of the patient triages were calculated.ResultsTriage by a single teledermatologist showed a sensitivity of 92.3% and a specificity of 58.7%. Sensitivity improved with the number of assessors, particularly when using the Caution Protocol, though with a considerable drop in specificity. The Majority Vote showed a more balanced improvement in sensitivity and specificity. Safety analyses indicated that diagnostic accuracy decreased with poor image quality and increased case difficulty.DiscussionExpert teledermoscopic triage of melanocytic skin lesions is highly sensitive and lowers the need for unnecessary excision procedures by half while dismissing as few as 0.4% (95% confidence interval 0-0.6%) of melanomas, even when applied to a high-prevalence pre-triaged subpopulation. Implementation of safety procedures increases accuracy. Using multiple teledermatologists increases sensitivity but at the cost of specificity unless a Majority Vote consensus strategy is applied. Future teledermoscopy guidelines should encompass safety procedures and protocols for disagreement between assessors.

IntroductionThe purpose of this study is to measure the comparative diagnostic accuracy of telehealth diagnostic examinations for pathologies of the shoulder against an in-person examination. The telehealth examinations were hypothesized to be non-inferior to in-person examinations for accuracy and to demonstrate fair to moderate agreement. This is an expanded study of a data set included in a prior publication.MethodsPatients underwent in-person standardized clinical examination (SCE) and standardized telehealth examination (STE) during the same visit by two different providers in randomized order. Tests were analyzed for sensitivity, specificity, agreement, and diagnostic accuracy using a nonarthrographic shoulder MRI as a reference standard, and divided into tests for rotator cuff tears (RCTs), glenohumeral arthritis (GHA), and acromioclavicular (AC) joint arthropathy. A pooled diagnostic accuracy was created for SCE and STE and directly compared using a Mann-Whitney U test.ResultsSixty-two patients, average age of 57.9 years (±11.2), with 60 patients obtaining an MRI, were included in this study. There were no significant differences in the pooled diagnostic accuracy of identifying RCT, GHA, or AC arthropathy between SCE and STE (P = .495, .469, .333, respectively). The highest agreement between SCE and STE was observed for the shoulder shrug test, night pain, and internal rotation limitation for identifying RCT.DiscussionSTE demonstrated non-inferior pooled diagnostic accuracy in comparison to SCE for full-thickness RCT, GHA, and AC joint arthropathy. Secondarily, there was moderate to substantial agreement for selective tests, with a considerable portion ranging from fair to substantial agreement.

IntroductionThe use of digital solutions including patient-reported outcomes is limited to follow-up of patients with established diagnoses but is rarely used as first step of the diagnostic process substituting a personal contact with a health professional. We report on the diagnostic validity and cost per patient implications based on a feasibility study of a new virtual diagnostic service (VDS) for common neurological sleep disorders that, as a first step, involves the collection and automated analysis of self-reported digital patient data.MethodsThe VDS was established at the Odense University Hospital, Denmark. Assessment of diagnostic validity of the underlying algorithm was conducted independently and blinded. Estimation of effects on cost per patient was based on administrative hospital cost data comparing similar periods before and after the introduction of VDS and estimates for travel and time consumption to assess the patients' economic benefits.ResultsA questionnaire-based algorithm was developed leveraging the diagnostic criteria of the American Academy of Sleep Medicine; comprehensibility was secured and improved by initial patient involvement. Parallel use of both the questionnaire and assessment by a senior sleep specialist of the first 20 patients revealed no discernible safety concerns and resulted in additional linguistic adaptions. The final questionnaire was completed by 123 of 157 patients (78.3%) identified as suitable for VDS. The questionnaire-based algorithm resulted in correct use of additional diagnostic procedures in 84 out of 95 patients with final diagnosis at data closure (88.4%, Cohen's kappa: 0.84). The algorithm proposed a specific diagnosis in 55 patients that was correct in 49.1% of cases (Cohen's kappa: 0.39). The economic analysis revealed a 46.7% reduction of the time from referral to diagnosis of the patient (226.5 days to 120.7 days). The average number of contacts with health professionals decreased from 2.15 to 1.26, the average direct costs per patients were reduced by 39.6% from 1811 Danish Kroner (DKK) to 1093 DKK. We estimated a 40.6% reduction of the total costs per patients from 3904 DKK to 2320 DKK including time consumption and travel costs.DiscussionThis first feasibility study indicates that use of digital diagnostic solutions as first step of the diagnostic process of neurological sleep disorders combined with an essentially complete virtual work flow has high accuracy and may be associated with reduced time for diagnostics and cost reductions for health providers and patients.

In this case, we describe the remote telehealth leadership of emergent tube thoracostomy in a patient with a critical respiratory status. The patient had presented to a small rural health care facility with breathlessness and hypoxia despite supplemental oxygen. A subsequent chest x-ray revealed a large pneumothorax requiring emergent treatment to prevent respiratory demise. Due to their location, the arrival of a critical care team would be delayed, and the local staff had very limited prior experience with chest procedures. Through remote telehealth leadership, the local team was guided through initial attempts at the Seldinger tube thoracostomy technique, before progressing to an open approach following failure of the initial attempt. Ultimately, the patient was stabilised and remained admitted locally, avoiding aeromedical retrieval. Key learnings included the need to develop a shared mental model of the procedure, responding to local equipment limitations, the leadership response to initial technique failure, and maintenance of situational awareness. This furthers evidence provided in prior case reports that high acuity low occurrence critical care procedures can be facilitated via remote telehealth support.

IntroductionThe rapid expansion of virtual ambulatory care has included both video and audio-only modalities. The impact of visit modality on patient experience is poorly understood, particularly in the interplay with social health determinants and technical aspects of virtual care. We sought to characterize differences in the patient-reported experience of virtual care between video and audio-only modalities, and to understand drivers of these differences.MethodsWe analyzed one year of ambulatory virtual visits with linked patient experience data from a US health system. Using nested logistic models, with a patient's likelihood to recommend the provider as the primary outcome, adjusting for patient- and physician-level covariates, we explored differences in experience by visit modality (video vs audio-only), including across demographic groups. We further assessed the impact of modality on patients' experience with technical aspects of virtual care.ResultsAmong 90,670 virtual encounters with patient experience data, 16% were audio-only. Compared with video-based encounters, audio-only visits were associated with lower likelihood to recommend overall (OR 0.75; 95%CI 0.70-0.80) and worse experience with many technical aspects. Black patients were more likely to have audio-only encounters and worse overall patient experience. This disparity persisted after adjusting for visit modality and was partly mediated by differences in perceived respectful provider communication and associated interpersonal aspects of care.DiscussionAudio-only virtual care remains central to ensuring access to care, but poses challenges for patient experience. Interventions and investments targeted at improving technical facets and provider communication are needed, particularly for ensuring equitable experience across racial groups.

IntroductionTo investigate the effectiveness of the remote video-based Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH) exercise program in individuals with rheumatoid arthritis (RA) with wrist involvement.MethodsSeventy-three individuals were included in the study. Wrist joint position sense, wrist joint range of motion, wrist pain, wrist morning stiffness, subjective and objective hand function, grip strength, and disease-related health status were assessed at baseline and after 12 weeks. Following the baseline assessment, participants were randomly assigned into two groups as SARAH and Control. All participants maintained their pharmacological therapy. The SARAH group received SARAH exercise videos via a free messaging platform (WhatsApp Messenger) weekly and performed the program daily for 12 weeks. No additional intervention was provided to the control group.ResultsForty-nine individuals (SARAH group = 28, control group = 21) completed all study procedures. Both per-protocol and intention-to-treat (ITT) analyses showed significant improvements in all parameters in the SARAH group (p < 0.05), while no statistically significant changes were detected in the control group (p > 0.05). When the changes were compared between the groups, SARAH group showed greater improvements regarding the changes in wrist joint position sense, wrist flexion, extension (only in ITT analysis) and radial deviation joint range of motion, wrist pain, wrist morning stiffness duration (only in ITT analysis), hand function, grip strength, and disease-related health status compared to the control group (p < 0.05).DiscussionA 12-week remote video-based SARAH exercise program provides additional benefits in individuals with RA who present wrist related problems when added to pharmacological therapy.

IntroductionThe Veterans Health Administration (VHA) prioritizes use of connected care technologies to enhance access and outcomes. The context in which connected care is implemented is crucial, yet difficult to measure, due to its subjective and complex nature. This evaluation examined alignment among stakeholder perceptions of context related to connected care implementation across VHA.MethodsA national, cross-sectional survey assessed perceptions of 11 contextual factors relevant to connected care implementation as identified in published reviews within the implementation science literature. Across 142 VHA facilities and 18 regions, surveys were sent to four stakeholder groups: clinical team members, connected care coordinators, facility leadership, and regional leadership. Mean scores for each factor were compared between stakeholder groups using Welch's ANOVA and Bonferroni-corrected post-hoc comparisons.ResultsA total of 5541 respondents (36.1% response rate) participated. Organizational Culture and Climate was rated the most favorable contextual factor (mean = 3.9, SD = 0.7), while Financial Resources was perceived as least favorable (mean = 3.0, SD = 1.0). Significant differences emerged between the perceptions of frontline workers (clinical team members, connected care coordinators) and leadership (facility, regional). Clinical team members rated nearly all contextual factors less favorably than facility leadership. Coordinators similarly rated most factors less favorably than leadership.DiscussionFindings highlight a misalignment between leadership and frontline workers in their perceptions of organizational context for implementing connected care technologies. Leadership viewed key contextual factors (e.g. Organizational Readiness to Change, Leadership Support) more favorably than frontline workers. This misalignment may impact implementation success, suggesting a need for strategies to better align stakeholder perceptions.

IntroductionSince 2021, the world has been facing a cost-of-living crisis which has negatively affected population health. Meanwhile, little is known about its impact on patients' preferences to access care. We aimed to analyse public preference for the modality of consultation (virtual vs face-to-face) before and after the onset of crisis and factors associated with these preferences.MethodsAn online cross-sectional survey was administered to the public in the United Kingdom, Germany, Italy and Sweden. McNemar tests were conducted to analyse pre- and post-crisis differences in preferences; logistic regression was used to examine the demographic factors associated with public preferences.ResultsSince the onset of crisis, the number of people choosing virtual consultations has increased in the United Kingdom (7.0% vs 9.5% P < 0.001), Germany (6.6% vs 8.6%, P < 0.008) and Italy (6.0% vs 9.8%, P < 0.001). Before the crisis, a stronger preference for virtual consultations was observed in people from urban areas (OR 1.28, 95% CI 1.05-1.56), while increasing age was associated with a lower preference for virtual care (OR 0.966, 95% CI 0.961-0.972). Younger people were more likely to switch to virtual care, while change to face-to-face was associated with younger age and lower income (OR 1.34, 95% CI 1.12-1.62). Older adults were less likely to change preference.ConclusionsSince the onset of the cost-of-living crisis, public preference for virtual consultations has increased, particularly in younger population. This contrasts with older adults and people with lower-than-average incomes. The rationale behind patients' preferences should be investigated to ensure patients can access their preferred modality of care.

IntroductionOsteoporotic hip fracture is a major health problem. Falls, the primary cause, might lead to a persistent fear of falling (FoF) among older adults, affecting their daily activities and rehabilitation. While in-person interventions exist, limited research is available on the effects of tele-rehabilitation on the FoF after a hip fracture. Thus, this study aims to test the association of the @ctivehip tele-rehabilitation programme on reducing the levels of FoF experienced by both older adults with hip fracture and their family caregivers.MethodsA non-randomised controlled trial (ClinicalTrials.gov; Identifier: NCT02968589) that compared a webpage-based tele-rehabilitation (@ctivehip) against usual care. Fear of falling was assessed using the Short Falls Efficacy Scale-International. Patients' functional status was evaluated using the Functional Independence Measure. Physical performance was assessed by the Timed Up and Go test and Short Physical Performance Battery. We conducted a per-protocol analysis as the primary outcome, and an intention-to-treat approach as secondary analysis.ResultsA total of 71 patients with hip fracture (78.75 ± 6.12 years, 75% women) and their family caregivers participated. Participants in the intervention showed a higher decrease in FoF in comparison to those in the usual care (0.5 Cohen's d; p = 0.042). The reduction in FoF resulting from participation in the tele-rehabilitation programme was mediated by improvements in functional status by 79%. The @ctivehip programme did not decrease FoF of family caregivers.Discussion@ctivehip is associated with a reduction of the FoF in older adults with hip fractures, but not in their family caregivers, with the reduction being mostly explained by improvements in the patients' functional status. Although the intervention seems promising, it should not be applied in clinical settings until confirmed by appropriate-designed randomised clinical trials.