Patient Satisfaction and Healthcare Utilization Using Telemedicine in Liver Transplant Recipients

Digitization of Follow-Up Care in Orthopedic and Trauma Surgery With Video Consultations: Health Economic Evaluation Study From a Health Provider's Perspective

BACKGROUND

Recommendations for health care digitization as issued with the Riyadh Declaration led to an uptake in telemedicine to cope with the COVID-19 pandemic. Evaluations based on clinical data are needed to support stakeholders' decision-making on the long-term implementation of digital health.

OBJECTIVE

This health economic evaluation aims to provide the first German analysis of the suitability of video consultations in the follow-up care of patients in orthopedic and trauma surgery, investigate the financial impact on hospital operations and personnel costs, and provide a basis for decisions on digitizing outpatient care.

METHODS

We conducted a randomized controlled trial that evaluated video consultations versus face-to-face consultations in the follow-up care of patients in orthopedic and trauma surgery at a German university hospital. We recruited 60 patients who had previously been treated conservatively or surgically for various knee or shoulder injuries. A digital health app and a browser-based software were used to conduct video consultations. The suitability of telemedicine was assessed using the Telemedicine Satisfaction Questionnaire and the EQ-5D-5L questionnaire. Economic analyses included average time spent by physician per consultation, associated personnel costs and capacities for additional treatable patients, and the break-even point for video consultation software fees.

RESULTS

After 4 withdrawals in each arm, data from a total of 52 patients (telemedicine group: n=26; control group: n=26) were used for our analyses. In the telemedicine group, 77% (20/26) of all patients agreed that telemedicine provided for their health care needs, and 69% (18/26) found telemedicine an acceptable way to receive health care services. In addition, no significant difference was found in the change of patient utility between groups after 3 months (mean 0.02, SD 0.06 vs mean 0.07, SD 0.17; P=.35). Treatment duration was significantly shorter in the intervention group (mean 8.23, SD 4.45 minutes vs mean 10.92, SD 5.58 minutes; P=.02). The use of telemedicine saved 25% (€2.14 [US $2.35]/€8.67 [US $9.53]) in personnel costs and increased the number of treatable patients by 172 annually, assuming 2 hours of video consultations per week. Sensitivity analysis for scaling up video consultations to 10% of the hospital's outpatient cases resulted in personnel cost savings of €73,056 (US $ 80,275.39) for a senior physician. A total of 23 video consultations per month were required to recoup the software fees of telemedicine through reduced personnel costs (break-even point ranging from 12-38 in the sensitivity analysis).

CONCLUSIONS

Our study supports stakeholders' decision-making on the long-term implementation of digital health by demonstrating that video consultations in the follow-up care of patients in orthopedic and trauma surgery result in cost savings and productivity gains for clinics with no negative impact on patient utility.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00023445; https://drks.de/search/en/trial/DRKS00023445.

Telehealth Experience Among Liver and Kidney Transplant Recipients: A Mixed Methods Study

Telehealth has become widely available to solid organ transplant (SOT) recipients during the COVID-19 pandemic. While evidence suggests that telehealth serves as an acceptable alternative for most SOT recipients, their satisfaction and its context remain unclear. This study used a mixed methods approach to investigate the perspectives of SOT recipients (i.e., liver, kidney, and simultaneous liver-kidney) on the benefits and disadvantages of telehealth. A total of 252 adult SOT recipients completed an online survey that quantitatively assessed telehealth experience and satisfaction. Fifteen of them further shared their perspectives by participating in either a focus group or individual interview. Approximately 70% of online survey participants had previously used telehealth for their transplant care. The quantitative data documented that, while recipients were mostly satisfied with telehealth, especially with its effectiveness and convenience, they were less satisfied with the reliability of navigating the telehealth system. The qualitative data further showed that telehealth could be less effective for SOT recipients who perceived themselves as clinically and/or socially vulnerable, needed urgent care, and were concerned about privacy. These findings suggest that the plan for using telehealth to provide transplant care should prioritize personalization, considering unique needs and preferences of each SOT recipient.

Design and evaluation of an educational mobile program for liver transplant patients

BACKGROUND

Liver transplantation, the last treatment for advanced liver failure, necessitates patient education due to its wide range of complications and subsequent disabilities. The present study was development-applied research and aimed to design a mobile-based educational program to provide liver transplant patients with critical health information.

METHODS

In the first phase of the study, the crucial educational components were collected from the literature and organized in the form of a questionnaire using library studies and available global guidelines. The validity and reliability of this researcher-made questionnaire were confirmed by a panel of experts (n = 15), including gastroenterologists and liver specialists working in the Motahari liver clinic and AbuAli Sina Hospital in Shiraz. The application was designed followed by analyzing the data gathered from the first phase. To evaluate the mobile phone program's usability, to evaluate the application, 30 liver transplant patients were randomly selected.

RESULTS

Most educational components covered in the questionnaire were deemed necessary by experts in the first phase. As a result, the educational contents were classified under 10 categories. The application had a good level of usability since the participants' satisfaction score was 8.1 (out of 9 points).

CONCLUSIONS

Due to the increase in liver transplantation and the use of mobile phones, applications increase the patient's role in their health, and their awareness. It also leads to a better interaction and follow-up of the patient, the treatment staff of the medical centers.

Using Telemedicine to Facilitate Patient Communication and Treatment Decision-Making Following Multidisciplinary Tumor Board Review for Patients with Hepatocellular Carcinoma

BACKGROUND AND AIMS

A rapid increase in the use of telemedicine for delivering healthcare has occurred since the onset of the Covid-19 pandemic. There is evidence for using telemedicine to facilitate cancer care delivery for patients with hepatocellular carcinoma (HCC). Examining how telemedicine can be used to communicate multidisciplinary tumor board (MTB) recommendations for HCC has not been studied. This study has two specific aims: (1) to evaluate the patient perspective of the MTB review process and identify best strategies for communicating treatment recommendations for HCC and (2) to pilot test a telemedicine intervention following MTB review to assess patient feasibility and satisfaction with using telemedicine to facilitate treatment decision-making and treatment referral.

METHODS

We conducted a mixed-methods study. First, semi-structured qualitative interviews were conducted among patients diagnosed with HCC who were discussed in MTB review at one of three VA Medical Centers (VAMC). We collected information about the MTB process from the patient perspective and identified strategies for improving communication and delivery of care. Rapid qualitative analysis was used to inform intervention development. Using our qualitative data, a MTB telemedicine pilot intervention was developed and implemented to assess the feasibility of using this approach for patients with HCC.

RESULTS

Almost all patients (94%) in the pilot study would recommend telemedicine to other patients with HCC, and half of the patients (50%) preferred telemedicine over in-person visits. Many patients (81%) found communication through telemedicine an acceptable platform to deliver difficult cancer information. Overall, patients felt they understood their treatment recommendations and found them clear and useful. Further, patients reported that they enjoyed being included in the decision-making process and appreciated being able to have family members easily join them for the telemedicine visit.

CONCLUSIONS

Using telemedicine to communicate treatment recommendations following MTB review was found to be feasible and an acceptable alternative to an in-person visit for patient with HCC. Future studies could include expanding this approach for communicating MTB recommendations to patients with other types of cancers.

A review of questionnaires used for the assessment of telemedicine

INTRODUCTION

Telemedicine is the exchange of medical information from one site to another via electronic communications with the goal of improving a patient's clinical health status. Prior studies have identified the absence of a standardized assessment tool for evaluating telemedicine encounters. This study aims to collect and to analyze questionnaires used for the assessment of audiovisual telemedicine encounters from a patient perspective and aims to identify reasons driving the use of self-developed questionnaires.

METHODS

We conducted a systematic search in PubMed for studies that used survey questionnaires to assess synchronous audiovisual telemedicine encounters from 2016 to 2021. We categorized questionnaires used into validated and non-validated types, and for each of them, collected questions, response format, author, year, specialty, and country of publication.

RESULTS AND DISCUSSION

We analyzed a total of 71 articles. We found that only 16 studies used three validated questionnaires. The remaining 55 studies used non-validated questionnaires. Non-validated questionnaires had a high variability in length and used Likert scales, binary responses, multiple choice, and open-ended answers. We found only eight studies in which the authors gave a reason for resorting to designing their own questionnaires. This review reveals insufficient standardized survey questionnaires to be used for the assessment of audiovisual telemedicine encounters. Future research initiatives should focus on developing a standardized and validated instrument well accepted by researchers.

Patient satisfaction with general surgery telephone consultations during the COVID-19 pandemic: a single surgeon experience

BACKGROUND

COVID-19 pandemic accelerated the development and use of telemedicine in surgical practice. Here we set out to understand patient satisfaction with the use of telephone consultation in the general surgical clinic and preference over face-to-face consultation.

METHODS

A prospective cohort study was carried out for consecutive patients seen in a general surgery telephone clinic by a single surgeon in a district general hospital in the UK from 1^st September 2021 to 10^th March 2022. Demographic data was collected from electronic patient records. At the end of the consultation patients were asked to: 1) score their satisfaction with the telephone consultation on a 5-point Likert Scale; and 2) whether they preferred telephone consultations to face-to-face appointments. It was noted if a patient required a further face-to-face consultation in addition to the telephone consultation.

RESULTS

The study included 245 patients who were reviewed by telephone consultation. Most patients (59.6%; N.=146) gave the telephone consultation the highest satisfaction score with a further 31% (N.=76) scoring it as a 4 out of 5. Only 2.8% of patients said they would have preferred a face-to-face consultation and gave a median satisfaction score of 2 (IQR 2-3) compared to 5 (IQR 4-5) in those who preferred telephone consultations (P<0.001).

CONCLUSIONS

Telemedicine is associated with high levels of patient satisfaction regardless of patient age or gender. Lower rates of satisfaction are associated with the need for further face-to-face follow-up. If telemedicine is to remain a permanent part of surgical practice, disease specific protocols for its use are required.

Factors Impacting Patient Perspectives on Telehealth and Remote Healthcare during COVID-19: A Mixed Methods Study

A rapid transformation to telehealth was a necessary precaution during the pandemic. This research sought a better understanding of factors impacting patients’ decisions on choosing telehealth. A mixed methods study was conducted with a sample of 276 patients. An online survey was used to collect qualitative and quantitative data. This study found that technical issues were the most significant factor preventing patients from using telehealth, among other factors such as waiting time and privacy concern. The results inform policy-makers and healthcare providers on how to optimize telehealth. The limitations of this study and future research directions are also discussed.

Liver transplantation during COVID-19: Adaptive measures with future significance

Following the outbreak of coronavirus disease 2019 (COVID-19), a disease caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the field of liver transplantation, along with many other aspects of healthcare, underwent drastic changes. Despite an initial increase in waitlist mortality and a decrease in both living and deceased donor liver transplantation rates, through the implementation of a series of new measures, the transplant community was able to recover by the summer of 2020. Changes in waitlist prioritization, the gradual implementation of telehealth, and immunosuppressive regimen alterations amidst concerns regarding more severe disease in immunocompromised patients, were among the changes implemented in an attempt by the transplant community to adapt to the pandemic. More recently, with the advent of the Pfizer BNT162b2 vaccine, a powerful new preventative tool against infection, the pandemic is slowly beginning to subside. The pandemic has certainly brought transplant centers around the world to their limits. Despite the unspeakable tragedy, COVID-19 constitutes a valuable lesson for health systems to be more prepared for potential future health crises and for life-saving transplantation not to fall behind.

Provider and Patient Satisfaction with Telemedicine Voice Therapy During the COVID-19 Pandemic

OBJECTIVES

The COVID-19 pandemic expanded the use of telemedicine, but there is no literature exploring both patient and provider satisfaction specifically in the provision of voice therapy. This study aims to investigate patient and provider satisfaction with virtual voice therapy, its associated factors, and any correlation between the two.

METHODS

Cross-sectional study. Participants included 226 adults who underwent voice therapy delivered via telepractice at the USC Voice Center between April and October 2020. Patients and providers self-reported their level of satisfaction on a visual analog scale (VAS; range 0-100). Patient satisfaction was additionally measured using a previously validated Telemedicine Satisfaction Questionnaire (TSQ; range 1-5), and a binary question about their desire to choose telemedicine over in-person therapy in the future. Three speech-language pathologists rated provider satisfaction for all 226 patients. Patient satisfaction survey was completed by 55 patients. Multivariable linear regression analyses and linear mixed-effects models were used to assess the results.

RESULTS

Patient and provider mean (SD) VAS satisfaction scores were 86.8 (18.6) and 80.6 (19.7), respectively. The mean (SD) TSQ score was 4.4 (0.6). In a multivariable model, patient satisfaction levels were significantly higher for hypofunctional than for hyperfunctional dysphonia diagnoses. Forty-four (73%) patients reported they would prefer telemedicine voice therapy over in-person appointments, which was significantly correlated with internet reliability (P = 0.04). For providers, satisfaction was significantly lower for patients whose diagnosis had changed after initiation of voice therapy (Δ = -16.0 [95% CI: -28.7 to -3.2]) and for encounters with Asian patients compared to White patients (Δ = -11.6 [95% CI: -18.9 to -4.2]). Patient and provider satisfaction scores were weakly correlated (r = 0.19).

CONCLUSIONS

Our findings suggest that virtual voice therapy is not simply an alternative to in-person service, but rather an effective method useful beyond the current pandemic with proper diagnosis and technical support.

Current Applications of Telemedicine in Gastroenterology

Telemedicine generally refers to the use of technology to communicate with patients and provide health care from a distance. Advances in technology, specifically computers, cellphones, and other mobile devices, have facilitated healthcare providers' growing ability to virtually monitor and mentor patients. There has been a progressive expansion in the use of telemedicine in the field of gastroenterology (GI), which has been accelerated by the COVID-19 pandemic. In this review, we discuss telemedicine-its history, various forms, and limitations-and its current applications in GI. Specifically, we focus on telemedicine in GI practice in general and specific applications, including the management of inflammatory bowel disease, celiac disease, and colorectal cancer surveillance and its use as an aid in endoscopic procedures.

Fast, cheap and feasible: Implementation of pediatric telemedicine in a public hospital during the Covid-19 pandemic

OBJECTIVE

In Brazil, telemedicine was allowed as an exception during the coronavirus disease (COVID-19) pandemic. Despite its recognized value and availability, telemedicine is not universally used, suggesting that some barriers prevent its adoption and acceptance within the community. This study aims to describe the implementation of a low-cost telemedicine service in a pediatric hospital in Brazil.

METHOD

Retrospective descriptive study reporting the first three months (April to June 2020) of the experience of implementing a low-cost telemedicine emergency care program in a public tertiary hospital. The service was available to patients up to 18 years of age enrolled in this hospital. A tool for assessing the severity of the patient was developed, the aim of standardizing the procedure, while maintaining quality and safety. Guardian's satisfaction was assessed with a questionnaire sent after teleconsultations.

RESULTS

255 teleconsultations were carried out with 140 different patients. Of the total consultations, 182 were from 99 patients that had performed the Real-Time Polymerase Chain Reaction (RT-PCR) test for the new coronavirus (SARS-Cov-2) or had direct contact with a person known to be positive for COVID-19. Only 26 (14%) were referred to an in-person consultation. No deaths, adverse events or delayed diagnosis were recorded. 86% of the patients who answered the satisfaction questionnaire were satisfied and 92% would use telemedicine again.

CONCLUSION

This study presents an innovative implementation of a telemedicine program in a public and exclusively pediatric tertiary service, serving as a reference for future implementation in other public services in Brazil and developing countries.

The digital transformation of hepatology: The patient is logged in

The rise in innovative digital health technologies has led a paradigm shift in health care toward personalized, patient-centric medicine that is reaching beyond traditional brick-and-mortar facilities into patients' homes and everyday lives. Digital solutions can monitor and detect early changes in physiological data, predict disease progression and health-related outcomes based on individual risk factors, and manage disease intervention with a range of accessible telemedicine and mobile health options. In this review, we discuss the unique transformation underway in the care of patients with liver disease, specifically examining the digital transformation of diagnostics, prediction and clinical decision-making, and management. Additionally, we discuss the general considerations needed to confirm validity and oversight of new technologies, usability and acceptability of digital solutions, and equity and inclusivity of vulnerable populations.

Telemedicine in Hepatology: Current Applications and Future Directions

Telemedicine refers to the use of information and communication technologies for providing health care at a distance. Through the use of telecommunication technologies such as cell phones, computers, and other electronic devices, health care providers are able to conduct patient visits, mentor/train other providers, and monitor patients' chronic diseases remotely, potentially hundreds or thousands of miles away. Over the past 2 decades, the use of telemedicine has grown in the field of hepatology. In this review, we provide a focused primer on telemedicine and its current applications in hepatology. In particular, we discuss the use of telemedicine in the management of chronic hepatitis C, the complications of liver disease, as well as preliver transplantation evaluation and posttransplantation care. In addition, we provide a synopsis of the effect of the coronavirus disease 2019 (COVID-19) pandemic on the use of telemedicine in hepatology.

Acceleration of mobile health for monitoring post-transplant in the COVID-19 era: Applications for pediatric settings

BACKGROUND

Since the start of the COVID-19 pandemic and consequent lockdowns, the use of telehealth interventions has rapidly increased both in the general population and among transplant recipients. Among pediatric transplant recipients, this most frequently takes the form of interventions on mobile devices, or mHealth, such as remote visits via video chat or phone, phone-based monitoring, and mobile apps. Telehealth interventions may offer the opportunity to provide care that minimizes many of the barriers of in-person care.

METHODS

The present review followed the PRISMA guidelines. Sources up until October 2020 were initially identified through searches of PsycInfo^® and PubMed^® .

RESULTS

We identified ten papers that reported findings from adult interventions and five studies based in pediatrics. Eight of the adult publications stemmed from the same two trials; within the pediatric subset, this was the case for two papers. Studies that have looked at mHealth interventions have found high acceptability rates over the short run, but there is a general lack of data on long-term use.

CONCLUSIONS

The literature surrounding pediatric trials specifically is sparse with all findings referencing interventions that are in early stages of development, ranging from field tests to small feasibility trials. The lack of research highlights the need for a multi-center RCT that utilizes robust measures of medication adherence and other outcome variables, with longer-term follow-up before telehealth interventions should be fully embraced.

Telemedicine in monitoring pediatric LT patients before and during COVID-19 pandemic

BACKGROUND

The delivery of healthcare services by telemedicine decreases costs of traveling for patients, is less time-consuming, and most importantly permits the connection between highly skilled specialists and patients. However, whether the use of telemedicine (text messaging) for LT patients was affected by the COVID-19 pandemic is unknown.

METHODS

We collected data (following consent from patients and parents) from 57 patients (33 male/24 female) with a median age of 47 (IQR: 9-91) months, whom we followed up with text messaging between September 2019 and September 2020, spanning the 6 months prior to COVID-19 and during this period.

RESULTS

In total, 723 text message mediated consultations occurred during this period, henceforth simply referred to as "messages." Three hundred and twenty-eight (45%) messages occurred during the 6 months up to the start of the pandemic. Following the COVID-19 outbreak, the number of messages increased to 395 (55%). The three most common reasons of messaging were post-liver-LT follow-up messages (n = 215/723, 29.7%), consultations for drug use (n = 157/723, 21.7%), and medication prescriptions (n = 113/723, 15.6%). Protocol biopsy discussions (n = 33/723, 4.6%) and fever (n = 27/723, 3.7%) were among others (vaccination, rash, diarrhea, cough, fatigue, acne). During the COVID-19 outbreak, only post-LT follow-up messages increased significantly to 132/395 (33%) from 83/328 (25%) (p-value: .02).

CONCLUSIONS

We found that the pandemic resulted in an increase in the total number of text message mediated consultations and specifically for the use of post-LT follow-up. Messaging was effective for post-LT follow-ups and all patients were at least satisfied.

Pediatric subspecialty telemedicine use from the patient and provider perspective

BACKGROUND

To characterize telemedicine use among pediatric subspecialties with respect to clinical uses of telemedicine, provider experience, and patient perceptions during the COVID-19 pandemic.

METHODS

We performed a mixed-methods study of telemedicine visits across pediatric endocrinology, nephrology, orthopedic surgery, and rheumatology at a large children's hospital. We used deductive analysis to review observational data from 40 video visits. Providers and patients/caregivers were surveyed around areas of satisfaction and communication.

RESULTS

We found adaptations of telemedicine including shared-screen use and provider-guided parent procedures among others. All providers felt that it was safest for their patients to conduct visits by video, and 72.7% reported completing some component of a clinical exam. Patients rated the areas of being respected by the clinical staff/provider and showing care and concern highly, and the mean overall satisfaction was 86.7 ± 19.3%.

CONCLUSIONS

Telemedicine has been used to deliver care to pediatric patients during the pandemic, and we found that patients were satisfied with the telemedicine visits during this stressful time and that providers were able to innovate during visits. Telemedicine is a tool that can be successfully adapted to patient and provider needs, but further studies are needed to fully explore its integration in pediatric subspecialty care.

IMPACT

This study describes telemedicine use at the height of the COVID-19 pandemic from both a provider and patient perspective, in four different pediatric subspecialties. Prior to COVID-19, pediatric telehealth landscape analysis suggested that many pediatric specialty practices had pilot telehealth programs, but there are few published studies evaluating telemedicine performance through the simultaneous patient and provider experience as part of standard care. We describe novel uses and adaptations of telemedicine during a time of rapid deployment in pediatric specialty care.

Factors Affecting Patient Perceptions and Satisfaction with Telemedicine in Outpatient Clinics

Despite the increasing use of telemedicine, patients' views on telemedicine remain unclear. This study aimed to understand factors affecting patient perceptions and satisfaction with telemedicine services. 235 patients were surveyed on accessibility to telemedicine clinics, medical specialities and satisfaction with the services. 58.3% confirmed having a stable internet connection, 24.3% used telemedicine services in internal medicine clinics, and only 5.1% accessed the telemedicine services in psychiatry clinics. 68.5% used the telephone to access telemedicine service, while only 6.4% used the hotline. Over half of patients confirmed their ability to hear clearly and speak easily with their healthcare providers during their consultations. 55.7% confirmed they were satisfied with their telemedicine experience, while 23.4% were neutral and 8.9% were unsatisfied. There was a significant difference in the rates of satisfaction between female and male respondents (p-value<0.001). Those with stable internet connection had significantly higher satisfaction rates with telemedicine services (p-value<0.001). The rates of satisfaction with telemedicine services were significantly higher in Cardiology and Orthopaedic clinics. Larger multi-center studies examining other factors affecting patients' satisfaction are recommended.

Psychosocial situation, adherence, and utilization of video consultation in young adult long-term pediatric liver transplant recipients during COVID-19 pandemic

BACKGROUND

Young adults who underwent liver transplantation in childhood (YALTs) are highly vulnerable to non-adherent behavior and psychosocial problems. During the COVID-19 pandemic, special efforts may be necessary to maintain contact with these patients and offer support. This can be achieved through the use of telemedicine. The study's objective was to assess adherence and the psychosocial situation of YALTs during the COVID-19 pandemic in Germany and to evaluate the utilization of video consultations.

METHODS

In May 2020, a questionnaire was sent to YALTs treated at the Hamburg University Transplant Center, accompanied by the offer of video appointments with the attending physician. The questionnaire included the Generalized Anxiety Disorder Scale 7, the Patient Health Questionnaire 2, and questions compiled by the authors.

RESULTS

Of 98 YALTs, 12% used the video consultation, while 65% had an in-person appointment. The 56 patients who completed the questionnaire did not report reduced medication adherence during the pandemic, but 40% missed follow-up visits with their primary care physician or check-up laboratory tests. About 70% of YALTs were afraid to visit their physician and the transplant center, and 34% were afraid of a SARS-CoV-2 infection. Mental health and well-being were unimpaired.

CONCLUSIONS

During the COVID-19 pandemic, YALTs in our study did not show an increased need for psychosocial support, but a majority were afraid to attend medical appointments, and 40% reported lower appointment adherence. Acceptance of video consultations was lower than expected. The reasons for this need to be further investigated in order to optimize care.

Patient-centered HCV care via telemedicine for individuals on medication for opioid use disorder: Telemedicine for Evaluation, Adherence and Medication for Hepatitis C (TEAM-C)

BACKGROUND

Telemedicine has the potential to increase healthcare access especially for vulnerable populations. Telemedicine for Evaluation, Adherence, and Medication for Hepatitis C (TEAM-C) is comparing telemedicine access to specialty medical care to usual care for management of hepatitis C virus (HCV) infection among persons with opioid use disorder (PWOUD). PWOUD have the highest hepatitis C virus (HCV) prevalence and incidence, yet they infrequently receive HCV care. The study objectives are to compare access to specialty care via telemedicine to offsite specialty referral (usual care) on 1) treatment initiation, completion, and sustained virological response, 2) patient satisfaction with health care delivery, and 3) HCV reinfection after successful HCV cure.

METHODS

TEAM-C is a multi-site, non-blinded, randomized pragmatic clinical trial conducted at 12 opioid treatment programs (OTP) throughout New York State that utilizes the stepped-wedge design. The unit of randomization is the OTP with a total sample size of 624 participants. HCV-infected PWOUD were treated via telemedicine or referral. Telemedicine encounters are conducted onsite in the OTP with co-administration of direct acting antivirals for HCV with medications for opioid use disorder. The primary outcome is undetectable HCV RNA obtained 12 weeks post-treatment cessation. We also follow participants for two years to assess for reinfection.

CONCLUSIONS

The study utilizes a rigorous study design to evaluate the effectiveness and implementation of virtual treatment for HCV integrated into behavioral treatment. We demonstrate the feasibility, engagement principles and lessons learned from the initial prospective randomized trial of telemedicine targeted to a vulnerable population.

Telemedicine for healthcare: Capabilities, features, barriers, and applications

Regular hospital visits can be expensive, particularly in rural areas, due to travel costs. In the era of the Covid-19 Pandemic, where physical interaction becomes risky, people prefer telemedicine. Fortunately, medical visits can be reduced when telemedicine services are used through video conferencing or other virtual technologies. Thus, telemedicine saves both the patient's and the health care provider time and the cost of the treatment. Furthermore, due to its fast and advantageous characteristics, it can streamline the workflow of hospitals and clinics. This disruptive technology would make it easier to monitor discharged patients and manage their recovery. As a result, it is sufficient to state that telemedicine can create a win-win situation. This paper aims to explore the significant capabilities, features with treatment workflow, and barriers to the adoption of telemedicine in Healthcare. The paper identifies seventeen significant applications of telemedicine in Healthcare. Telemedicine is described as a medical practitioner to diagnose and treat patients in a remote area. Using health apps for scheduled follow-up visits makes doctors and patients more effective and improves the probability of follow-up, reducing missing appointments and optimising patient outcomes. Patients should have an accurate medical history and show the doctor any prominent rashes, bruises, or other signs that need attention through the excellent quality audio-video system. Further, practitioners need file management and a payment gateway system. Telemedicine technologies allow patients and doctors both to review the treatment process. However, this technology supplements physical consultation and is in no way a substitute for a physical consultation. Today this technology is a safe choice for patients who cannot go to the doctor or sit at home, especially during a pandemic.

Remote Consultations Versus Standard Face-to-Face Appointments for Liver Transplant Patients in Routine Hospital Care: Feasibility Randomized Controlled Trial of myVideoClinic

Background

Using technology to reduce the pressure on the National Health Service (NHS) in England and Wales is a key government target, and the NHS Long-Term Plan outlines a strategy for digitally enabled outpatient care to become mainstream by 2024. In 2020, the COVID-19 response saw the widespread introduction of remote consultations for patient follow-up, regardless of individual preferences. Despite this rapid change, there may be enduring barriers to the effective implementation of remote appointments into routine practice once the unique drivers for change during the COVID-19 pandemic no longer apply, to which pre-COVID implementation studies can offer important insights.

Objective

This study aims to evaluate the feasibility of using real-time remote consultations between patients and secondary care physicians for routine patient follow-up at a large hospital in the United Kingdom and to assess whether patient satisfaction differs between intervention and usual care patients.

Methods

Clinically stable liver transplant patients were randomized to real-time remote consultations in which their hospital physician used secure videoconferencing software (intervention) or standard face-to-face appointments (usual care). Participants were asked to complete postappointment questionnaires over 12 months. Data were analyzed on an intention-to-treat basis. The primary outcome was the difference in scores between baseline and study end by patient group for the three domains of patient satisfaction (assessed using the Visit-Specific Satisfaction Instrument). An embedded qualitative process evaluation used interviews to assess patient and staff experiences.

Results

Of the 54 patients who were randomized, 29 (54%) received remote consultations, and 25 (46%) received usual care (recruitment rate: 54/203, 26.6%). The crossover between study arms was high (13/29, 45%). A total of 129 appointments were completed, with 63.6% (82/129) of the questionnaires being returned. Patient satisfaction at 12 months increased in both the intervention (25 points) and usual care (14 points) groups. The within-group analysis showed that the increases were significant for both intervention (P<.001) and usual care (P=.02) patients; however, the between-group difference was not significant after controlling for baseline scores (P=.10). The qualitative process evaluation showed that—according to patients—remote consultations saved time and money, were less burdensome, and caused fewer negative impacts on health. Technical problems with the software were common, and only 17% (5/29) of patients received all appointments over video. Both consultants and patients saw remote consultations as positive and beneficial.

Conclusions

Using technology to conduct routine follow-up appointments remotely may ease some of the resource and infrastructure challenges faced by the UK NHS and free up clinic space for patients who must be seen face-to-face. Our findings regarding the advantages and challenges of using remote consultations for routine follow-ups of liver transplant patients have important implications for service organization and delivery in the postpandemic NHS.

Trial Registration

ISRCTN Registry 14093266; https://www.isrctn.com/ISRCTN14093266

International Registered Report Identifier (IRRID)

RR2-10.1186/s13063-018-2953-4

Telemedicine in Otolaryngology During COVID-19: Patient and Physician Satisfaction

OBJECTIVE

To examine patient and physician satisfaction with telemedicine in otolaryngology during COVID-19 and identify associated factors.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary care center.

METHODS

Patient satisfaction was rated by patients (age ≥18 years) who had encounters from May to July 2020 (n = 407). Physician satisfaction was rated by 15 otolaryngologists for specific encounters delivered from May to June 2020 (n = 1011). Patient satisfaction was measured with a Press Ganey questionnaire and a Telemedicine Satisfaction Questionnaire. Mean Press Ganey satisfaction scores of telemedicine encounters during COVID-19 were compared with the pre-COVID-19 Press Ganey scores from in-person encounters (n = 3059) to test a noninferiority hypothesis. Physician satisfaction was measured with a Provider Satisfaction Questionnaire.

RESULTS

The mean Press Ganey patient satisfaction score for telemedicine encounters was 94.5 (SD, 8.8), no worse than that for in-person encounters prior to COVID-19 at 93.7 (SD, 15.5; Δ = 0.8 [95% CI, -0.5 to 2.1, excluding the noninferiority margin of -1]). Encounters with videoconference (vs telephone) and patients reporting higher income were associated with higher Telemedicine Satisfaction Questionnaire scores. Physician satisfaction scores during COVID-19 with telemedicine encounters were overall high at 83.3 (95% CI, 77.5-89.1), slightly lower when compared with the scores with in-person encounters at 88.4 (95% CI, 82.5-94.3; Δ = -5.2 [95% CI, -6.6 to -3.8]). Encounters with videoconference (vs telephone) and patients with English as a preferred language and follow-up visits were associated with higher Provider Satisfaction Questionnaire scores.

CONCLUSIONS

Telemedicine is a feasible alternative format in otolaryngology during COVID-19 with overall high patient and physician satisfaction. Patient satisfaction with telemedicine encounters during COVID-19 was no worse than in-person encounters prior to the pandemic. Physician satisfaction with telemedicine was relatively lower in comparison with in-person encounters.

The role of telemedicine in the postoperative home monitoring after robotic colo-rectal cancer surgery: a preliminary single center experience

The telemedicine studies, takes care and prevents diseases at distance basing on the interaction among physicians and patients remotely. Few data are available on its application to early postoperative after surgery. The endpoints of our preliminary experience were the detection, as primary, of feasibility and safety of home telemonitoring after robotic colo-rectal resection and, as secondary, perception and satisfaction of the patients. From December 2019 to March 2020, at the Division of Robotic Surgery of San Giovanni Hospital of Rome, 20 of 29 colorectal cancer patients, submitted to Robotic resection, were prospectively included in a program of postoperative home telemonitoring. Telemonitoring was considered feasible if at least 75% of data were available and safe if morbidity ≤ II by Clavien-Dindo classification. Perception and patients' satisfaction were evaluated through a dedicated questionnaire. Out of 20 patients, the median age was 68 years, overall postoperative morbidity was 30%, all events classified Clavien-Dindo Grade I or II. Only 2 patients were corresponded to surgical consult without readmission during home telemonitoring. Compliance of patients was > 80%, overall grade of satisfaction was very high: 4.2 as median (range 0-5). In this preliminary study, the procedures of postoperative home telemonitoring were feasible and safe and high rate of patients' satisfaction was observed. The telemedicine could enhance the role of robotic technique in decrease the hospital stay and improving postoperative recovery after surgery. Further structured prospective trial are needed to validate the routine application of telemedicine in healthcare.

Telemedicine in the COVID-19 era for Liver Transplant Recipients: an Italian lockdown area experience

BACKGROUND

Data on COVID-19 in Liver Transplant (LT) recipients are scanty, but one can hypothesize that they are more susceptible to infection due to chronic immunosuppression. Telemedicine could be an alternative to the routine clinical care in this difficult period. We aimed to investigate in a cohort of LT recipients the access to remote consultation and the attitude towards Telemedicine using an internet-based survey.

MATERIAL AND METHODS

We invited LT recipients from the Liver Transplant Follow-up Center of the University Hospital of Salerno to access remote consultation. A subgroup of them also participated in a self-administered, internet-based survey evaluating demographics; LT data and immunosuppressive therapy; comorbidities; attitudes towards COVID-19 infection; their perceptions of the need for health care, and their approach to telemedicine.

RESULTS

Seventy-four/one hundred and fifty-three (48.3%) LT recipients were unable to access remote consultation. They showed a significantly higher mean age and a higher percentage of low school degree compared to those who accessed it (p=0.03 and p=0.001, respectively). Among the remaining LT recipients, 50/79 (63.3%) responded to the survey; mean time from liver transplantation was 12±7 years; 94% of the sample reported at least one comorbidity; 44% of LT recipients declared to be "very much/much" worried because of COVID-19 infection, and 64% considered themselves more vulnerable than the general population. Forty percent of responders refused the routine follow-up visit, and 62% were very interested in using Telemedicine.

CONCLUSION

LT recipients were anxious because of COVID-19 infection and considered themselves more vulnerable than the general population, refusing the routine clinical visit. For continuing services during the COVID-19 era, new strategies are needed and telemedicine shows promise.

Integrated Healthcare and the Dilemma of Public Health Emergencies

Traditional healthcare services have demonstrated structural shortcomings in the delivery of patient care and enforced numerous elements of integration in the delivery of healthcare services. Integrated healthcare aims at providing all healthcare that makes humans healthy. However, with mainly chronically ill people and seniors, typically suffering from numerous comorbidities and diseases, being recruited for care, there is a need for a change in the healthcare service structure beyond direct-patient care to be compatible in peacetime and during public health emergencies. This article’s objective is to discuss the opportunities and obstacles for increasing the effectiveness of healthcare through improved integration. A rapid evidence review approach was used by performing a systematic followed by a non-systematic literature review and content analysis. The results confirmed that integrated healthcare systems play an increasingly important role in healthcare system reforms undertaken in European Union countries. The essence of these changes is the transition from the episodic treatment of acute diseases to the provision of coordinated medical services, focused on chronic cases, prevention, and ensuring patient continuity. However, integrated healthcare, at a level not yet fully defined, will be necessary if we are to both define and attain the integrated practice of both global health and global public health emergencies. This paper attains the necessary global challenges to integrate healthcare effectively at every level of society. There is a need for more knowledge to effectively develop, support, and disseminate initiatives related to coordinated healthcare in the individual healthcare systems.

Fast track pathway provides safe, value based care on busy acute care surgery service

BACKGROUND

Fast track (FT) pathways have been adopted across a multitude of elective surgeries but have been slow to be adopted into the acute care surgery realm. We hypothesized that an FT pathway for acute cholecystitis patients would decrease patient length of stay and resource utilization.

METHODS

All patients at two hospitals, one with an FT pathway and one with a traditional pathway, who underwent an urgent laparoscopic cholecystectomy for acute cholecystitis between May 1, 2019, and October 31, 2019, were queried using CPT codes. Exclusion criteria were conversion to open or partial cholecystectomy. Retrospective chart review was used to gather demographics, operative, hospital course, and outcomes. Time to operating room, hospital length of stay, and resource utilization were the primary outcomes.

RESULTS

There was a total of 479 urgent laparoscopic cholecystectomies performed, 430 (89.8%) were performed under the FT pathway. The median (interquartile range [IQR]) time to the operating room was not different: 14.1 hours (IQR, 8.3-29.0 hours) for FT and 18.5 hours (IQR, 11.9-25.9 hours) for traditional (p = 0.316). However, the median length of stay was shorter by 15.9 hours in the FT cohort (22.6 hours; IQR, 14.2-40.4 hours vs. 38.5 hours; IQR, 28.3-56.3 hours; p < 0.001). Under the FT pathway, 33.0% of patients were admitted to the hospital and 75.6% were discharged from the postanesthesia care unit, compared with 91.8% and 12.2% on the traditional pathway (both p < 0.001). There were 59.6% of the FT patients that received a phone call follow up, as opposed to 100% of the traditional patients having clinic follow up (p < 0.001). The emergency department bounce back rate, readmission rates, and complication rates were similar (p > 0.2 for all). On multivariate analysis, having a FT pathway was an independent predictor of discharge within 24 hours of surgical consultation (odds ratio, 7.65; 95% confidence interval< 2.90-20.15; p < 0.001).

CONCLUSION

Use of a FT program for patients with acute cholecystitis has a significant positive impact on resource utilization without compromise of clinical outcomes.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

A summary of eye-related visits to a tertiary emergency department

Timely ophthalmologic consultation is important to ensure patients receive high quality ophthalmologic care in the Emergency Department (ED). Tele-ophthalmology may prove useful in safely and efficiently managing ED eye-related complaints. Prior to implementing such a solution, current consultation patterns must be understood. We aimed to assess case-mix acuity and consultation workflow patterns in the ophthalmology consult service at a tertiary emergency department in New York City. The medical records of patients with eye-related complaints who presented to the ED between January 1, 2015 and December 31, 2015 were reviewed. Visits were retrospectively assigned acuities and the ophthalmologic subspecialty involved in the case was recorded. The number of ophthalmologic consultations ordered and consultant response times were analyzed. Patients who were transferred to the ED for eye-related complaints were included. The ED received 1090 eye-related complaints in this period. 60% were retrospectively assigned low acuity, 27% were assigned medium acuity, and 13% were assigned high acuity. Ophthalmology was consulted on 19% of low, 18% of medium, and 48% of high acuity cases. 44% of complaints involved the anterior segment and 30% involved oculoplastics. 2/3 of transfer patients initially assigned high acuity were downgraded to low acuity upon examination. On average, the consult note was created and signed within 109 and 153 min, respectively, after consult order. ED consults are heavily weighted towards pathology of low-to-medium acuity affecting the anterior segment and ocular adnexa. Currently available tele-ophthalmology technology can potentially address a large volume of eye-related visits.

The most used questionnaires for evaluating telemedicine services

Background

Questionnaires are commonly used tools in telemedicine services that can help to evaluate different aspects. Selecting the ideal questionnaire for this purpose may be challenging for researchers. This study aims to review which questionnaires are used to evaluate telemedicine services in the studies, which are most common, and what aspects of telemedicine evaluation do they capture.

Methods

The PubMed database was searched in August 2020 to retrieve articles. Data extracted from the final list of articles included author/year of publication, journal of publication, type of evaluation, and evaluation questionnaire. Data were analyzed using descriptive statistics.

Results

Fifty-three articles were included in this study. The questionnaire was used for evaluating the satisfaction (49%), usability (34%), acceptance (11.5%), and implementation (2%) of telemedicine services. Among telemedicine specific questionnaires, Telehealth Usability Questionnaire (TUQ) (19%), Telemedicine Satisfaction Questionnaire (TSQ) (13%), and Service User Technology Acceptability Questionnaire (SUTAQ) (5.5%), were respectively most frequently used in the collected articles. Other most used questionnaires generally used for evaluating the users’ satisfaction, usability, and acceptance of technology were Client Satisfaction Questionnaire (CSQ) (5.5%), Questionnaire for User Interaction Satisfaction (QUIS) (5.5%), System Usability Scale (SUS) (5.5%), Patient Satisfaction Questionnaire (PSQ) (5.5%), and Technology Acceptance Model (TAM) (3.5%) respectively.

Conclusion

Employing specifically designed questionnaires or designing a new questionnaire with fewer questions and more comprehensiveness in terms of the issues studied provides a better evaluation. Attention to user needs, end-user acceptance, and implementation processes, along with users' satisfaction and usability evaluation, may optimize telemedicine efforts in the future.

Keeping the lights on: Telehealth, testing, and 6-month outcomes for orthotopic liver transplantation during the COVID-19 pandemic

Background

The coronavirus disease 2019 (COVID-19) pandemic has seen transplant volume decrease nationwide, resulting in a 2.2-fold increase in waitlist mortality. In particular, solid organ transplant patients are subjected to increased morbidity and mortality from infection. In the face of these challenges, transplant centers need to develop innovative protocols to ensure high-quality care.

Methods

A multidisciplinary protocol was developed that included the following: virtual selection meetings, coronavirus disease 2019 negative donors, pretransplant symptom screening, rapid testing on presentation, telehealth follow-up, and weekly community outreach town halls. All orthotopic liver transplants completed between January 2018 and August 2020 were included in the study (n = 344). The cohort was stratified from January 2018 to February 2020 as “pre-COVID-19,” and from March 2020 to August 2020 as “COVID-19.” Patient demographics and postoperative outcomes were compared.

Results

From March 2020 to August 2020, there was a significant decrease in average monthly referrals for orthotopic liver transplantation (29.8 vs 37.1, P = .01). However, listings (11.0 vs 14.3, P = .09) and transplant volume remained unchanged (12.2 vs 10.6, P = .26). Rapid testing was utilized on arrival for transplant, zero patients tested positively preoperatively, and median time from test result until abdominal incision was 4.5 h [interquartile range, 1.2, 9.2]. Simultaneously, telehealth visits increased rapidly, peaking at 85% of all visits. It is important to note that there was no difference in outcomes between cohorts.

Conclusion

Orthotopic liver transplant can be accomplished safely and effectively in the COVID-19 era without compromising outcomes through increasing utilization of telehealth, rapid COVID-19 testing, and multidisciplinary protocols for managing immunosuppressed patients.

Feasibility of telehealth in the management of autoimmune hepatitis before and during the COVID-19 pandemic

OBJECTIVES

We aimed to evaluate the feasibility of telehealth in the management of patients with autoimmune hepatitis (AIH). The COVID-19 outbreak during the study period provided an opportunity to evaluate any pandemic influence on how telehealth was perceived by patients and physicians.

METHODS

We included patients with AIH who were followed in the Harran University hospital, Turkey. Patients were managed by either remote telehealth or standard care.

RESULTS

A total of 46 (telehealth, n=19 and standard care, n= 27) patients (40 female) with a median age of 32 (range 17-74) years at diagnosis were included in the study. Until the start of the COVID-19 pandemic, the rates of biochemical remission and relapse after remission were similar in the telehealth and standard care groups (89.5% vs. 89.1% and 15.8% vs. 25.9%, p=ns, for both). The telehealth group maintained remission significantly better than the standard care group (100% vs. 77.3%, p=0.035) during the COVID-19 period. All relapses were due to non-adherence to therapy. Psychiatric problems, pregnancy-related issues and drug side-effects could all be managed remotely by telehealth.

CONCLUSIONS

In this study, we show for the first time that telehealth is a feasible alternative for managing AIH, both under normal circumstances and during the COVID-19 pandemic.

EXPERT OPINION

Autoimmune hepatitis (AIH) requires long-life lifelong immunosuppression and follow-up for most patients. The use of telehealth may be an alternative way to evaluate these patients remotely. We show for the first time that telehealth is effective and useful in the management of AIH in regular time as well during COVID-19. We hope that our study can extend use of telehealth in the evaluation of patients with other causes of chronic liver disease.

Use of Telemedicine for Chronic Liver Disease at a Single Care Center During the COVID-19 Pandemic: Prospective Observational Study

Background

The COVID-19 outbreak has overwhelmed and altered health care systems worldwide, with a substantial impact on patients with chronic diseases. The response strategy has involved implementing measures like social distancing, and care delivery modalities like telemedicine have been promoted to reduce the risk of transmission.

Objective

The aim of this study was to analyze the benefits of using telemedicine services for patients with chronic liver disease (CLD) at a tertiary care center in Italy during the COVID-19–mandated lockdown.

Methods

From March 9 to May 3, 2020, a prospective observational study was conducted in the Liver Unit of the University Hospital of Naples Federico II to evaluate the impact of (1) a fully implemented telemedicine program, partially restructured in response to COVID-19 to include video consultations; (2) extended hours of operation for helpline services; and (3) smart-working from home to facilitate follow-up visits for patients with CLD while adhering to social distancing regulations.

Results

During the lockdown in Italy, almost 400 visits were conducted using telemedicine; only patients requiring urgent care were admitted to a non–COVID-19 ward of our hospital. Telemedicine services were implemented not only for follow-up visits but also to screen patients prior to hospital admission and to provide urgent evaluations during complications. Of the nearly 1700 patients with CLD who attended a follow-up visit at our Liver Unit, none contracted COVID-19, and there was no need to alter treatment schedules.

Conclusions

Telemedicine was a useful tool for following up patients with CLD and for reducing the impact of the COVID-19 pandemic. This system of health care delivery was appreciated by patients since it gave them the opportunity to be in contact with physicians while respecting social distancing rules.

Impact of mobile health and medical applications on clinical practice in gastroenterology

Mobile health apps (MHAs) and medical apps (MAs) are becoming increasingly popular as digital interventions in a wide range of health-related applications in almost all sectors of healthcare. The surge in demand for digital medical solutions has been accelerated by the need for new diagnostic and therapeutic methods in the current coronavirus disease 2019 pandemic. This also applies to clinical practice in gastroenterology, which has, in many respects, undergone a recent digital transformation with numerous consequences that will impact patients and health care professionals in the near future. MHAs and MAs are considered to have great potential, especially for chronic diseases, as they can support the self-management of patients in many ways. Despite the great potential associated with the application of MHAs and MAs in gastroenterology and health care in general, there are numerous challenges to be met in the future, including both the ethical and legal aspects of applying this technology. The aim of this article is to provide an overview of the current status of MHA and MA use in the field of gastroenterology, describe the future perspectives in this field and point out some of the challenges that need to be addressed.

Use of Telehealth Expedites Evaluation and Listing of Patients Referred for Liver Transplantation

BACKGROUND & AIMS

Liver transplantation is the only treatment that increases survival times of patients with decompensated cirrhosis. Patients who live farther away from a transplant center are disadvantaged. Health care delivery via telehealth is an effective way to manage patients with decompensated cirrhosis remotely. We investigated the effects of telehealth on the liver transplant evaluation process.

METHODS

We performed a retrospective study of 465 patients who underwent evaluation for liver transplantation at the Richmond Veterans Affairs Medical Center from 2005 through 2017. Of these, 232 patients were evaluated via telehealth, and 233 via in-person evaluation. Using regression models, we evaluated the differential effects of telehealth vs usual care on placement on the liver transplant waitlist. We also investigated the effects of telehealth on time from referral to initial evaluation by a transplant hepatologist, liver transplantation, and mortality.

RESULTS

Patients in the telehealth group were evaluated significantly faster than patients evaluated in person, without or with adjustment for potential confounders (21.7 vs 79.5 d; P < .01). Telehealth also was associated with a significantly shorter time on the liver transplant waitlist (138.8 vs 249 d; P < .01). After propensity-matched analysis, telehealth was associated with a reduction in the time from referral to evaluation (hazard ratio, 0.15; 95% CI, 0.09-0.21; P < .01) and listing (hazard ratio, 0.26; 95% CI, 0.12-0.40; P < .01), but not to transplantation. In the intent-to-treat analysis of all referred patients, we found no significant difference in pretransplant mortality between patients evaluated via telehealth vs in-person. There was statistically significant interaction between model for end-stage liver disease (MELD)-Na scores and time to evaluation (P = .009) and placement on the transplant waitlist (P = .002), with telehealth offering greater benefits to patients with low MELD-Na scores.

CONCLUSIONS

Use of telehealth is associated with a substantial reduction in time from referral to initial evaluation by a hepatologist and placement on the liver transplant waitlist, especially for patients with low MELD scores, with no changes in time to transplantation or pretransplant mortality. More studies are needed, particularly outside of the Veterans Administration Health System, to confirm that telehealth is a safe and effective way to expand access for patients undergoing evaluation for liver transplantation.

Telemedicine Based Remote Home Monitoring After Liver Transplantation: Results of a Randomized Prospective Trial

OBJECTIVE

This study assesses the impact of a telemedicine-based home management program (THMP) on patient adherence, hospital readmissions, and quality of life (QOL) after liver transplantation (LT).

SUMMARY OF BACKGROUND DATA

Telemedicine interventions represent an opportunity to personalize care and can lead to improved adherence and patient satisfaction. However, there is limited data on impact of these interventions on outcomes after LT. Therefore, we conducted the first randomized controlled trial (RCT) of a THMP compared to standard of care (SOC) after LT.

METHODS

One hundred six consecutive LT recipients were randomized (1:1) to 1 of 2 posttransplant care strategies: SOC or THMP. The THMP included an electronic tablet and bluetooth devices to support daily text messages, education videos, and video FaceTime capability; data was cyber-delivered into our electronic medical record daily. Endpoints were THMP participation, 90-day hospital readmission rate, and QOL.

RESULTS

One hundred patients completed the study with 50 enrolled in each arm. Participation and adherence with telemedicine was 86% for basic health sessions (vital sign recording), but only 45% for using messaging or FaceTime. The THMP group had a lower 90-day readmission rate compared to SOC (28% vs 58%; P = 0.004). The THMP cohort also showed improved QOL in regards to physical function (P = 0.02) and general health (P = 0.05) at 90 days.

CONCLUSIONS

To our knowledge, this is the first RCT demonstrating the impact of THMP after LT. The magnitude of effect on LT outcomes, hospital readmissions, and QOL suggests that the adoption of telemedicine has great potential for other major operations.

Telemedicine Improves Access to Hepatology Consultation with High Patient Satisfaction

AIMS

Telemedicine between health care providers could be useful for improving the access to hepatology consultations, which is challenging in some regions. The primary objective of this study was to estimate the proportion of consultations that were resolved through a telemedicine program. Additionally, we evaluated patient satisfaction with this strategy.

METHODS

Consecutive telemedicine consultations made by non-hepatologist health care providers from different regions of Argentina to a specialty hepatology team were included. Participants and hepatologists used e-mail, teleconference systems, WhatsApp, or telephone to interact, depending on their preferences. Consultations were considered to be resolved through telemedicine when a diagnosis and an adequate follow-up were achieved without the need to refer the patient to a hepatologist or other specialist. Patient satisfaction with telemedicine was evaluated using the Patient Satisfaction Questionnaire Short Form and Telemedicine Satisfaction Questionnaire.

RESULTS

A total of 200 telemedicine consultations made by 24 physicians from 10 different provinces of Argentina were evaluated, of which 145 (73%; 95% CI: 66%-79%) were resolved through telemedicine. Practitioners specialities were as follows: family physicians, internists, gastroenterologists, infectious diseases, and obstetrics. The most frequent final diagnoses for those patients whose consultation was resolved through telemedicine were non-alcoholic fatty liver disease, viral hepatitis, and benign hepatic lesions. A high degree of patient satisfaction with telemedicine was observed in both questionnaires.

CONCLUSIONS

Our results show the effectiveness of telemedicine in hepatology, with high resolution rate of consultations and rapid access to experts' assessment. Additionally, a high degree of patient satisfaction was observed using prevalidated questionnaires.

Follow-up of liver transplant recipients

The number of surviving liver allograft recipients is increasing almost exponentially. The quality and length of life is increasing but most recipients have reduced survival and quality of life compared with healthy matched individuals. Causes of premature death include cardio and cerebrovascular disease, renal failure, graft failure, de novo malignancy and recurrent disease. Follow-up is needed lifelong to ensure graft and patient health and ensure that complications are recognised and treated early. Immunosuppression is kept to the appropriate minimum and prophylactic interventions are given early, such as use of statins and tight control of blood pressure and blood sugar. Recipients will require life-long follow-up, and this is placing an increasing burden on transplant units. Follow-up is best done by close collaboration between the Liver Transplant Unit, the local hospital and primary care team. Involvement of other health care practitioners, such as recipient coordinators, pharmacists, dermatologists and addiction specialists may improve outcomes. Key to successful follow-up are agreed protocols and good communication between the recipients and all relevant health care providers. Use of IT allows for better communication and will support use of video and telephone consultations in selected instances. The most appropriate follow-up will depend on many factors, including logistic and geographic issues, local experience. The provision of well-funded and supported registries at local, national and international levels will allow for improvements in management.

Successful implementation of remote video consultations for patients receiving home parenteral nutrition in a national UK Centre

RATIONALE

Our intestinal failure unit provides care for patients from a wide geographical area. Patients dependent on home parenteral nutrition (HPN) are routinely reviewed in the clinic at 3-6 monthly intervals. Between March 2008 and 2015, we noted a significant rise in the number of patients under our care, with an associated 51% increase in clinic appointments offered. We evaluated whether telemedicine would provide a strategy to reduce patients' need to travel while maintaining safe clinical standards.

METHODS

Implementation began in December 2015 via patient consultation and small tests of change. Clinical data were obtained from a prospectively maintained database. Remote video consultation discussions were carried out via internet video call service (Skype). An anonymous satisfaction questionnaire was offered to patients for completion following consultation. The number of miles saved by obviating the need to attend hospital was calculated for each patient.

RESULTS

During the study period, patients receiving HPN rose by 18% to 288. Twenty-five patients used telemedicine for HPN follow-up, three of these for follow-up with the psychologist. By avoiding hospital attendance, this saved a mean travel distance of 56.7 miles with a total of 18 346.6 cumulative miles saved. Sixty-three per cent of patients rated their satisfaction with the system at ≥90%, with a mean satisfaction of 85%. Eight per cent of the telemedicine cohort was admitted with an HPN complication, compared with an admission rate of 24% for the whole HPN cohort. One emergency admission was avoided.

CONCLUSION

Telemedicine can obviate the need for clinic attendance in HPN-dependent patients, so reducing the need of individuals with chronic illness to travel while maintaining standards for follow-up.

Improving cirrhosis care: The potential for telemedicine and mobile health technologies

Decompensated cirrhosis is a condition associated with significant morbidity and mortality. While there have been significant efforts to develop quality metrics that ensure high-value care of these patients, wide variations in clinical practice exist. In this opinion review, we discuss the quality gap in the care of patients with cirrhosis, including low levels of compliance with recommended cancer screening and other clinical outcome and patient-reported outcome measures. We posit that innovations in telemedicine and mobile health (mHealth) should play a key role in closing the quality gaps in liver disease management. We highlight interventions that have been performed to date in liver disease and heart failure-from successful teleconsultation interventions in the care of veterans with cirrhosis to the use of telemonitoring to reduce hospital readmissions and decrease mortality rates in heart failure. Telemedicine and mHealth can effectively address unmet needs in the care of patients with cirrhosis by increasing preventative care, expanding outreach to rural communities, and increasing high-value care. We aim to highlight the benefits of investing in innovative solutions in telemedicine and mHealth to improve care for patients with cirrhosis and create downstream cost savings.