Telemedicine interventions for older adults: A systematic review

INTRODUCTION

Telemedicine may help improve older adults' access, health outcomes, and quality of life indicators. This review aims to provide current evidence on the effectiveness of telemedicine in the aged population.

METHOD

A systematic literature search was conducted in PubMed, Google Scholar, and Web of Science electronic databases between January 2015 and September 2021 using the keywords "telemedicine" or "telehealth" and "older people" or "geriatrics" or "elderly." The articles were classified under three headings according to the purposes: feasibility, diagnosis and management of chronic diseases, and patient satisfaction.

RESULTS

A total of 22 articles were included. Across most disciplines, evidence has shown that telemedicine is as effective as usual care, if not more so, in the feasibility, chronic disease management, and patient satisfaction of the elderly. However, a few studies reported challenges such as difficulty with technology, hearing problems, and the inability to perform hands-on examinations for physicians.

CONCLUSION

Findings from this review support the view that health care providers can use telemedicine to manage elderly individuals in conjunction with usual health care. However, future research is needed to eliminate barriers to increasing telemedicine use among older adults.

GP perceptions of telehealth services in Australia: a qualitative study

BACKGROUND

Primary care providers have been rapidly transitioning from in-person to telehealth care during the 2019 coronavirus (COVID-19) pandemic. There is an opportunity for new research in a rapidly evolving area, where evidence for telehealth services in primary care in the Australian setting remains limited.

AIM

To explore general practitioner (GP) perceptions on providing telehealth (telephone and video consultation) services in primary care in Australia.

DESIGN & SETTING

A qualitative study using semi-structured interviews to gain an understanding of GP perceptions on telehealth use in Australia.

METHOD

GPs across Australia were purposively sampled. Semi-structured interviews were conducted, recorded, and transcribed verbatim for analysis. Transcripts were analysed using inductive thematic analysis to identify initial codes, which were then organised into themes.

RESULTS

Fourteen GPs were interviewed. Two major themes that described GP perceptions of telehealth were: (1) existence of business and financial pressures in general practice; and (2) providing quality of care in Australia. These two themes interacted with four minor themes: (3) consumer-led care; (4) COVID-19 as a driver for telehealth reimbursement and adoption; (5) refining logistical processes; and (6) GP experiences shape telehealth use.

CONCLUSION

This study found that multiple considerations influenced GP choice of in-person, videoconference, or telephone consultation mode. For telehealth to be used routinely within primary care settings, evidence that supports the delivery of higher quality care to patients through telehealth and sustainable funding models will be required.

Specialist consultation activity and costs in Australia: Before and after the introduction of COVID-19 telehealth funding

This study describes and analyses the Medicare Benefits Schedule (MBS) activity and cost data for specialist consultations in Australia, as a result of the coronavirus disease 2019 (COVID-19) pandemic. To achieve this, activity and cost data for MBS specialist consultations conducted from March 2019 to February 2021 were analysed month-to-month. MBS data for in-person, videoconference and telephone consultations were compared before and after the introduction of COVID-19 MBS telehealth funding in March 2020. The total number of MBS specialist consultations claimed per month did not differ significantly before and after the onset of COVID-19 (p = 0.717), demonstrating telehealth substitution of in-person care. After the introduction of COVID-19 telehealth funding, the average number of monthly telehealth consultations increased (p < 0.0001), representing an average of 19% of monthly consultations. A higher proportion of consultations were provided by telephone when compared to services delivered by video. Patient-end services did not increase after the onset of COVID-19, signifying a divergence from the historical service delivery model. Overall, MBS costs for specialist consultations did not vary significantly after introducing COVID-19 telehealth funding (p = 0.589). Telehealth consultations dramatically increased during COVID-19 and patients continued to receive specialist care. After the onset of COVID-19, the cost per telehealth specialist consultation was reduced, resulting in increased cost efficiency to the MBS.

Strategies for reducing out of pocket payments in the health system: a scoping review

Background

Direct out-of-pocket payments (OOP) are among the most important financing mechanisms in many health systems, especially in developing countries, adversely affecting equality and leading vulnerable groups to poverty. Therefore, this scoping review study was conducted to identify the strategies involving OOP reduction in health systems.

Methods

Articles published in English on strategies related to out-of-pocket payments were Searched and retrieved in the Web of Science, Scopus, PubMed, and Embase databases between January 2000 and November 2020, following PRISMA guidelines. As a result, 3710 papers were retrieved initially, and 40 were selected for full-text assessment.

Results

Out of 40 papers included, 22 (55%) and 18 (45%) of the study were conducted in developing and developed countries, respectively. The strategies were divided into four categories based on health system functions: health system stewardship, creating resources, health financing mechanisms, and delivering health services.As well, developing and developed countries applied different types of strategies to reduce OOP.

Conclusion

The present review identified some strategies that affect the OOP payments According to the health system functions framework. Considering the importance of stewardship, creating resources, the health financing mechanisms, and delivering health services in reducing OOP, this study could help policymakers make better decisions for reducing OOP expenditures.

Improving continuity by bringing the cancer patient, general practitioner and oncologist together in a shared video-based consultation - protocol for a randomised controlled trial

BACKGROUND

Strengthening the coordination, continuity and intersectoral cooperation for cancer patients' during cancer treatment is being underlined by international guidelines and research. General practitioners have assumed a growing role in the cancer patient disease trajectory because of their roles as coordinators and the consistent health provider. However, general practitioners are challenged in providing support for cancer patients both during treatment and in the survivorship phase. General practitioners reported barriers are lack of timely and relevant communication from the oncologist and limited knowledge to guidelines, as well as lack of trust from patients. Therefore, the current study will examine whether a shared video-based consultation between the cancer patient, general practitioner and oncologist can ease general' challenges and thereby enhance the patient-centeredness for the cancer patients and their perception of intersectoral cooperation and continuity.

METHODS

The study is designed as a pragmatic randomised controlled trial for patients starting chemotherapy at the Department of Oncology, Lillebaelt Hospital, Denmark who are listed with a general practitioner in the Region of Southern Denmark. We intend to include 278 adults diagnosed with colorectal, breast, lung, gynecologic or prostate cancer. The intervention group will receive the "Partnership intervention" which consists of one or more video-consultations between the cancer patient, general practitioner and oncologist. The consultations are estimated to last between 10 and 20 min. The specific aims of the consultation are, summary of the patient trajectory, sharing of knowledge regarding comorbidity, psychosocial resources and needs, physical well-being, medicine, anxiety and depression symptoms, spouses, workability and late complication and side-effects to the cancer treatment.

DISCUSSION

Video-based consultation that brings the cancer patient, the general practitioner and the oncologist together in the early phase of treatment may facilitate a sense of partnership that is powerful enough to improve the patient's perception of intersectoral cooperation, continuity of cancer care and health-related quality of life.

TRIAL REGISTRATION

ClincialTrials.gov Identifier: NCT02716168 . Date of registration: 03.03.2016.

The Impact of Access Barriers on Fertility Treatment Decision Making: A Qualitative Study From the Perspectives of Patients and Service Providers

OBJECTIVE

The purpose of this study was to explore how barriers to accessing fertility services affect the treatment decisions made by fertility patients and service providers in Newfoundland and Labrador.

METHODS

Semistructured, in-depth interviews were conducted with 11 patients across Newfoundland and with eight service providers from Newfoundland and Labrador Fertility Services (located in St. John's) to gather the perspectives of both patients and providers. The interview transcripts were analyzed thematically.

RESULTS

Patients' responses to fertility service access barriers included choosing cheaper drugs, substituting intrauterine insemination (IUI) for IVF or not using IVF, delaying IVF, choosing more accessible IVF clinics, transferring multiple embryos, and stopping treatment altogether. Some patients, however, noted that the barriers would not stop them from continuing with treatment. Providers' responses to the barriers patients faced included changing drug protocols, manipulating ovulation, providing teleconsultations, and minimizing patients' clinic visits for those living some distance away from St. John's.

CONCLUSION

Both patients and providers make treatment-related decisions to maximize the likelihood of a successful pregnancy and to reduce costs, which can result in less effective care and at times increased risk to the patient. Unlike with other types of care, responses to barriers to fertility treatment largely result in changes to individual patient treatment plans rather than changing models of care. As a result, many patients must continue to seek fertility services in large urban centres and incur substantial personal costs.

Providing Cardiology Care in Rural Areas Through Visiting Consultant Clinics

BACKGROUND

Workforce experts predict a future shortage of cardiologists that is expected to impact rural areas more severely than urban areas. However, there is little research on how rural patients are currently served through clinical outreach. This study examines the impact of cardiology outreach in Iowa, a state with a large rural population, on participating cardiologists and on patient access.

METHODS AND RESULTS

Outreach clinics are tracked annually in the Office of Statewide Clinical Education Programs Visiting Medical Consultant Database (University of Iowa Carver College of Medicine). Data from 2014 were analyzed. In 2014, an estimated 5460 visiting consultant clinic days were provided in 96 predominantly rural cities by 167 cardiologists from Iowa and adjoining states. Forty-five percent of Iowa cardiologists participated in rural outreach. Visiting cardiologists from Iowa and adjoining states drive an estimated 45 000 miles per month. Because of monthly outreach clinics, the average driving time to the nearest cardiologist falls from 42.2±20.0 to 14.7±11.0 minutes for rural Iowans. Cardiology outreach improves geographic access to office-based cardiology care for more than 1 million Iowans out of a total population of 3 million. Direct travel costs and opportunity costs associated with physician travel are estimated to be more than $2.1 million per year.

CONCLUSIONS

Cardiologists in Iowa and adjoining states have expanded access to office-based cardiology care from 18 to 89 of the 99 counties in Iowa. In these 71 counties without a full-time cardiologist, visiting consultant clinics can accommodate more than 50% of office visits in the patients' home county.

Integrating Telemental Healthcare with the Patient-Centered Medical Home Model

OBJECTIVE

The purpose of this article is to discuss how telemental healthcare and the patient-centered medical home (PCMH) can be integrated to improve the quality of mental healthcare available.

METHODS

This article outlines the components of a PCMH, and how the needs of this type of system of care can benefit from telemental healthcare.

RESULTS

The princples of PCMHs are being increasingly promoted in a variety of settings. In order to fulfill these principles, mental heathcare must be a integral part of the care provided to patients within the PCMH. The mental healthcare workforce is inadequate to provide care for patients, particularly in rural and high-poverty areas. Telemental healthcare provides a means to extend mental health services to the PCMHs using a variety of models.

CONCLUSIONS

Telemental healthcare offers unique opportunities to bridge the need for mental healthcare integration in the PCMH for all patients.

Telehealth: experience of the first 120 consultations delivered from a new refugee telehealth clinic

BACKGROUND

In 2011, the Australian Government introduced Medicare item numbers for telehealth consultations. This is a rapidly expanding method of healthcare provision.

AIMS

We assessed the demographic and disease profile of refugee patients attending a new telehealth clinic, and calculated the patient travel avoided. We examined technical challenges and assessed the performance of two videoconferencing solutions using different bandwidth and latencies.

METHODS

We audited the first 120 patients attending the telehealth clinic. During consultations, the patient was with the general practitioner (GP) and linked by internet videoconference using VIDYO, GoToMeeting or Skype, to the specialist at a tertiary referral hospital. Travel avoided was calculated and technical problems were assessed by the participating specialist. Bandwidth and latency variations were examined within a university broadband testing facility.

RESULTS

The two most frequently managed conditions were hepatitis C and latent tuberculosis. Twenty-nine different GP were included and 42 consultations required an interpreter. Nearly 500 km of travel and 127 kg of CO(2) production was avoided per consultation. Technical issues were faced in 25% of consultations, most frequently sound problems and connections dropping out. A bandwidth of at least 512 kbps and latency of no more than 300 ms was necessary to conduct an adequate multipoint videoconference.

CONCLUSIONS

Telehealth using videoconferencing adds a new component to care of refugee and immigrant patients settling in regional areas. Telehealth will be improved by changes to improve simplicity and standardisation of videoconferencing, but requires ongoing Medicare funding to allow sufficient administrative support.

A call centre and extended checklist for pre-screening elective surgical patients – a pilot study

Background

Novel approaches to preoperative assessment and management before elective surgery are warranted to ensure that a sustainable high quality service is provided. The benefits of a call centre incorporating an extended preoperative electronic checklist and phone follow-up as an alternative to a clinic attendance were examined.

Methods

This was a pilot study of a new method of patient assessment in patients scheduled for elective non-cardiac surgery and who attended a conventional preoperative clinic. A call centre assessment, using a Computer-assisted Health Assessment by Telephone (CHAT), paper review by an anaesthetist, and a follow-up phone call if the anaesthetist wished more information, preceded the conventional preoperative clinic. Summaries from the call centre and clinic assessments were independently produced.

The times spent by call centre staff were recorded. The ‘procedural anaesthetist’ (who provided anaesthesia for each patient’s actual surgery/procedure) documented an opinion on whether the call centre assessment alone would have been sufficient to bypass the preoperative clinic if the patient were hypothetically undergoing laparoscopic cholecystectomy. This opinion was also sought from a panel of four senior anaesthetists, based on patient summaries from both the call centre and preoperative clinic, but expanded to three hypothetical operations of different complexity – cataract removal, laparoscopic cholecystectomy, and total hip replacement.

Results

Call centre assessment followed by clinic attendance was studied in 193 patients. The mean time for CHAT was 19.8 (SD 7.5) minutes and, after review of CHAT summaries, anaesthetists telephoned 45.6 % of cases for follow-up information. The mean time spent by anaesthetists on summary review and phone calls was 3.8 (SD 3.9) minutes. Procedural anaesthetists considered 89 % of the patients under their care suitable to have bypassed the preoperative clinic if they were to have undergone cholecystectomy. The panel of senior anaesthetists judged 95-97 % of patients suitable to have bypassed preoperative clinic for cataract surgery, 81-85 % for cholecystectomy and 79-82 % for hip replacement.

Conclusions

A call centre to pre-screen elective surgical patients might substantially reduce patient numbers attending preoperative anaesthetic assessment clinics. Further studies to assess the quality of such an approach are indicated.

Trial registration

ANZCTRACTRN12614000199617.

Telemedicine--is the cart being put before the horse?

A large literature base on telemedicine exists, but the evidence base for telemedicine is very limited. There is little practical or useful information to guide clinicians and health policymakers. Telemedicine is often implemented based on limited or no prior formal analysis of its appropriateness to the circumstances, and adoption of telemedicine by clinicians has been slow and patchy. Formal analysis should be conducted before implementation of telemedicine to identify the patients, conditions and settings that it is likely to benefit. Primary studies of telemedicine tend to be of insufficient quality to enable synthesis of formal evidence. Methods typically used to assess effectiveness in medicine are often difficult, expensive or impractical to apply to telemedicine. Formal studies of telemedicine should examine efficacy, effectiveness, economics and clinician preferences. Successful adoption and sustainable integration of telemedicine into routine care could be improved by evidence-based implementation.