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The Impact of Virtual Care in an Emergency Department Observation Unit. Ann Emerg Med 2023; 81:222-233. [PMID: 36253299 DOI: 10.1016/j.annemergmed.2022.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/29/2022] [Accepted: 07/06/2022] [Indexed: 01/25/2023]
Abstract
STUDY OBJECTIVE(S) We report the impact of telemedicine virtual rounding in emergency department observation units (EDOU) on the effectiveness, safety, and cost relative to traditional observation care. METHODS In this retrospective diff-in-diff study, we compared observation visit outcomes from 2 EDOUs before (pre) and after (post) full adoption of telemedicine rounding tele-observation (tele-obs) with usual care in control EDOU and care in a hospital bed in an integrated health system without tele-obs. Tele-obs physicians did not work at the control hospital. Outcomes were the length of stay, total direct costs, admission status, and adverse events (ICU and death). Difference-in-differences modeling evaluated outcomes with covariates including age, sex, payer type, and clinical classification software diagnostic category. Data from a system data warehouse and a cost accounting database were used. RESULTS Of the 20,861 EDOU visits, 15,630 (74.9%) were seen in the preperiod and 6,657 (31.9%) in control EDOU. Of 23,055 non-EDOU inpatient visits assigned to observation status (nonobservation unit), 76% were seen in the preperiod. Adjusted length of stay was not significantly different for tele-obs and control EDOUs (26.4 hours versus 23.5 hours), which remained lower than in hospital settings (37.9 hours). The pre-post diff-in-diff was not significant (P=.78). Inpatient admission status was similar for tele-obs and control EDOUs (20.9% versus 22.4.%) and lower than in hospital settings (30.3%). Prepost odds ratios for inpatient admission and adverse outcomes did not change significantly for all study groups. Adjusted costs increased over time for all settings; however, the prepost median cost change was not significantly different between tele-obs EDOUs and control EDOUs ($162.5 versus $235) and was lower than the change for control hospital settings ($783). Median tele-obs EDOU cost over both periods ($1,541) remained significantly lower than hospital costs ($2,413). CONCLUSION Using tele-obs to manage observation patients in an ED observation unit was not associated with significant differences in length of stay, admission status, measured adverse events, or total direct cost.
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Totten AM, Womack DM, Griffin JC, McDonagh MS, Davis-O'Reilly C, Blazina I, Grusing S, Elder N. Telehealth-guided provider-to-provider communication to improve rural health: A systematic review. J Telemed Telecare 2022:1357633X221139892. [PMID: 36567431 DOI: 10.1177/1357633x221139892] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Telehealth may address healthcare disparities for rural populations. This systematic review assesses the use, effectiveness, and implementation of telehealth-supported provider-to-provider collaboration to improve rural healthcare. METHODS We searched Ovid MEDLINE®, CINAHL®, EMBASE, and Cochrane CENTRAL from 1 January 2010 to 12 October 2021 for trials and observational studies of rural provider-to-provider telehealth. Abstracts and full text were dual-reviewed. We assessed the risk of bias for individual studies and strength of evidence for studies with similar outcomes. RESULTS Seven studies of rural uptake of provider-to-provider telehealth documented increases over time but variability across geographic regions. In 97 effectiveness studies, outcomes were similar with rural provider-to-provider telehealth versus without for inpatient consultations, neonatal care, outpatient depression and diabetes, and emergency care. Better or similar results were reported for changes in rural clinician behavior, knowledge, confidence, and self-efficacy. Evidence was insufficient for other clinical uses and outcomes. Sixty-seven (67) evaluation and qualitative studies identified barriers and facilitators to implementing rural provider-to-provider telehealth. Success was linked to well-functioning technology, sufficient resources, and adequate payment. Barriers included lack of understanding of rural context and resources. Methodologic weaknesses of studies included less rigorous study designs and small samples. DISCUSSION Rural provider-to-provider telehealth produces similar or better results versus care without telehealth. Barriers to rural provider-to-provider telehealth implementation are common to practice change but include some specific to rural adaptation and adoption. Evidence gaps are partially due to studies that do not address differences in the groups compared or do not include sufficient sample sizes.
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Affiliation(s)
| | - Dana M Womack
- Oregon Health & Science University, Portland, OR, USA
| | | | | | | | - Ian Blazina
- Oregon Health & Science University, Portland, OR, USA
| | - Sara Grusing
- Oregon Health & Science University, Portland, OR, USA
| | - Nancy Elder
- Oregon Health & Science University, Portland, OR, USA
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Gutierrez J, Rewerts K, CarlLee S, Kuperman E, Anderson ML, Kaboli PJ. A systematic review of telehealth applications in hospital medicine. J Hosp Med 2022; 17:291-302. [PMID: 35535926 DOI: 10.1002/jhm.12801] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 01/12/2022] [Accepted: 01/28/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Despite the proliferation of telehealth, uptake for acute inpatient services has been slower. Hospitalist shortages in rural and critical access hospitals as well as the COVID-19 pandemic have led to a renewed interest in telehealth to deliver acute inpatient services. Understanding current evidence is crucial for promoting uptake and developing evidence-based practices. OBJECTIVE To conduct a systematic review of telehealth applications in acute inpatient general medicine and pediatric hospital wards and synthesize available evidence. DATA SOURCES A search of five databases (PubMed, CINAHL, Embase, Scopus, and ProQuest Theses, and Dissertations) using a combination of search terms including telemedicine and hospital medicine/inpatient care keywords yielded 17,015 citations. STUDY SELECTION AND DATA EXTRACTION Two independent coders determined eligibility based on inclusion and exclusion criteria. Data were extracted and organized into main categories based on findings: (1) feasibility and planning, (2) implementation and technology, and (3) telehealth application process and outcome measures. RESULTS Of the 20 publications included, three were feasibility and planning studies describing the creation of the program, services provided, and potential cost implications. Five studies described implementation and technology used, including training, education, and evaluation methods. Finally, twelve discussed process and outcome measures, including patient and provider satisfaction and costs. CONCLUSION Telehealth services for hospital medicine were found to be effective, well received, and initial cost estimates appear favorable. A variety of services were described across programs with considerable benefit appreciated by rural and smaller hospitals. Additional work is needed to evaluate clinical outcomes and overall program costs.
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Affiliation(s)
- Jeydith Gutierrez
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City, Iowa City VA Healthcare System, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Kelby Rewerts
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City, Iowa City VA Healthcare System, Iowa City, Iowa, USA
- The Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System, Iowa City, Iowa, USA
| | - Sheena CarlLee
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Fayetteville, Arkansas, USA
| | - Ethan Kuperman
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Melver L Anderson
- Department of Internal Medicine, University of Colorado Anschutz School of Medicine, Denver, Colorado, USA
| | - Peter J Kaboli
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City, Iowa City VA Healthcare System, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- The Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System, Iowa City, Iowa, USA
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Haydon HM, Snoswell CL, Thomas EE, Broadbent A, Caffery LJ, Brydon JA, Smith AC. Enhancing a community palliative care service with telehealth leads to efficiency gains and improves job satisfaction. J Telemed Telecare 2021; 27:625-630. [PMID: 34726990 DOI: 10.1177/1357633x211048952] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Telepalliative care services enable clinicians to provide essential palliation services to people with a life-limiting illness in or closer to home. This study aims to explore the costs, service activity and staff experiences resulting from the introduction of telehealth in a community palliative care service in Queensland, Australia. Pre- and post-activity and cost data from the 2016-2017 and 2019-2020 financial years were examined and staff members interviewed. Accounting for inflation and standard wage increases, the labour costs before and after the addition of telehealth were approximately equal. There were small variations in non-labour costs, but these were not directly attributable to the expansion of the telehealth services. Overall, the service activity increased by 189% for standard doctor and nurse consultations, due to the increased efficiency of telehealth compared to the previous outreach (travel) model. Thematic analysis of the staff interview data generated an overarching theme of Increased Job Satisfaction which staff attributed to the patient-centred nature of the telepalliative care service, the increased peer support and increased professional development. Compared with the traditional in-person service, the new telehealth-supported model resulted in equivalent costs, greater efficiency by allowing palliative care to reach more patients and improved staff job satisfaction.
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Affiliation(s)
- Helen M Haydon
- Centre for Online Health, 1974The University of Queensland, Australia
- Centre for Health Services Research, 1974The University of Queensland, Australia
| | - Centaine L Snoswell
- Centre for Online Health, 1974The University of Queensland, Australia
- Centre for Health Services Research, 1974The University of Queensland, Australia
| | - Emma E Thomas
- Centre for Online Health, 1974The University of Queensland, Australia
- Centre for Health Services Research, 1974The University of Queensland, Australia
| | - Andrew Broadbent
- 3556Gold Coast Specialist and Supportive Palliative Care Service, Gold Coast Hospital, Australia
| | - Liam J Caffery
- Centre for Online Health, 1974The University of Queensland, Australia
- Centre for Health Services Research, 1974The University of Queensland, Australia
| | - Julie-Ann Brydon
- 3556Gold Coast Specialist and Supportive Palliative Care Service, Gold Coast Hospital, Australia
| | - Anthony C Smith
- Centre for Online Health, 1974The University of Queensland, Australia
- Centre for Health Services Research, 1974The University of Queensland, Australia
- Centre for Innovative Medical Technology, University of Southern Denmark, Denmark
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Zanotto BS, Etges APBDS, Marcolino MAZ, Polanczyk CA. Value-Based Healthcare Initiatives in Practice: A Systematic Review. J Healthc Manag 2021; 66:340-365. [PMID: 34192716 PMCID: PMC8423138 DOI: 10.1097/jhm-d-20-00283] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
EXECUTIVE SUMMARY Value-based initiatives are growing in importance as strategic models of healthcare management, prompting the need for an in-depth exploration of their outcome measures. This systematic review aimed to identify measures that are being used in the application of the value agenda. Multiple electronic databases (PubMed/MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials) were searched. Eligible studies reported various implementations of value-based healthcare initiatives. A qualitative approach was used to analyze their outcome measurements. Outcomes were classified according to a tier-level hierarchy. In a radar chart, we compared literature to cases from Harvard Business Publishing. The value agenda effect reported was described in terms of its impact on each domain of the value equation. A total of 7,195 records were retrieved; 47 studies were included. Forty studies used electronic health record systems for data origin. Only 16 used patient-reported outcome surveys to cover outcome tiers that are important to patients, and 3 reported outcomes to all 6 levels of our outcome measures hierarchy. A considerable proportion of the studies (36%) reported results that contributed to value-based financial outcomes focused on cost savings. However, a gap remains in measuring outcomes that matter to patients. A more complete application of the value agenda by health organizations requires advances in technology and culture change management.
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Affiliation(s)
- Bruna Stella Zanotto
- National Institute of Health Technology Assessment and Graduate Program in Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Ana Paula Beck da Silva Etges
- National Institute of Health Technology Assessment, Federal University of Rio Grande do Sul, and Pontifical Catholic University of Rio Grande do Sul Polytechnic School, Porto Alegre, Brazil
| | - Miriam Allein Zago Marcolino
- National Institute of Health Technology Assessment, Federal University of Rio Grande do Sul and Graduate Program in Epidemiology, Federal University of Rio Grande do Sul; and
| | - Carisi Anne Polanczyk
- National Institute of Health Technology Assessment, Federal University of Rio Grande do Sul, and Graduate Programs in Epidemiology and Cardiology and Cardiovascular Sciences, Federal University of Rio Grande do Sul
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Gutierrez J, Moeckli J, Holcombe A, O’Shea AMJ, Bailey G, Rewerts K, Hagiwara M, Sullivan S, Simon M, Kaboli P. Implementing a Telehospitalist Program Between Veterans Health Administration Hospitals: Outcomes, Acceptance, and Barriers to Implementation. J Hosp Med 2021; 16:156-163. [PMID: 33617436 PMCID: PMC7929612 DOI: 10.12788/jhm.3570] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 11/12/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Telehospitalist services are an innovative alternative approach to address staffing issues in rural and small hospitals. OBJECTIVE To determine clinical outcomes and staff and patient satisfaction with a novel telehospitalist program among Veterans Health Administration (VHA) hospitals. DESIGN, SETTING, AND PARTICIPANTS We conducted a mixed-methods evaluation of a quality improvement program with pre- and postimplementation measures. The hub site was a tertiary (high-complexity) VHA hospital, and the spoke site was a 10-bed inpatient medical unit at a rural (low-complexity) VHA hospital. All patients admitted during the study period were assigned to the spoke site. INTERVENTION Real-time videoconferencing was used to connect a remote hospitalist physician with an on-site advanced practice provider and patients. Encounters were documented in the electronic health record. MAIN OUTCOMES Process measures included workload, patient encounters, and daily census. Outcome measures included length of stay (LOS), readmission rate, mortality, and satisfaction of providers, staff, and patients. Surveys measured satisfaction. Qualitative analysis included unstructured and semi-structured interviews with spoke-site staff. RESULTS Telehospitalist program implementation led to a significant reduction in LOS (3.0 [SD, 0.7] days vs 2.3 [SD, 0.3] days). The readmission rate was slightly higher in the telehospitalist group, with no change in mortality rate. Satisfaction among teleproviders was very high. Hub staff perceived the service as valuable, though satisfaction with the program was mixed. Technology and communication challenges were identified, but patient satisfaction remained mostly unchanged. CONCLUSION Telehospitalist programs are a feasible and safe way to provide inpatient coverage and address rural hospital staffing needs. Ensuring adequate technological quality and addressing staff concerns in a timely manner can enhance program performance.
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Affiliation(s)
- Jeydith Gutierrez
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center – Iowa City, Iowa City VA Healthcare System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Corresponding Author: Jeydith Gutierrez, MD; ; Telephone: (319) 356-4019. Twitter: @JeydithMd
| | - Jane Moeckli
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center – Iowa City, Iowa City VA Healthcare System, Iowa City, Iowa
- The Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, Iowa
| | - Andrea Holcombe
- The Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, Iowa
| | - Amy MJ O’Shea
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center – Iowa City, Iowa City VA Healthcare System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- The Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, Iowa
| | - George Bailey
- The Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, Iowa
| | - Kelby Rewerts
- The Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, Iowa
| | - Mariko Hagiwara
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Steven Sullivan
- Acute Care Services, Tomah VA Medical Center, Tomah, Wisconsin
| | - Melissa Simon
- Acute Care Services, Tomah VA Medical Center, Tomah, Wisconsin
| | - Peter Kaboli
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center – Iowa City, Iowa City VA Healthcare System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- The Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, Iowa
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