Design and performance of a multi-centre randomised controlled trial and economic evaluation of joint tele-consultations [ISRCTN54264250]

Use of tranexamic acid in medial open wedge high tibial osteotomy

PURPOSE

Aim of this study was to evaluate the effect of tranexamic acid (TXA) on the outcome after medial open wedge osteotomy.

MATERIAL AND METHODS

A prospective non-randomized comparative study with 52 patients has been performed. In both treatment groups, the same surgical technique for the medial open wedge HTO was used. In group 1 (N: 26) the patients received 1 g TXA i.v. preoperatively, in group 2 (N: 26) no TXA was given. Primary outcome measure was the decrease in hemoglobin concentration. Secondary outcome criteria were postoperative pain, intraarticular effusion (measured by ultrasound), range of motion (ROM) at discharge, peri- and postoperative complications and the KOOS PS (pre- and postoperatively at 1 year follow up).

RESULTS

Hemoglobin decrease was significantly less in the TXA group compared to the non TXA group. Postoperative pain and intraarticular effusion was also significantly lower and ROM at discharge was higher in the TXA group. There was no group difference in peri- and postoperative complications and the pre- and postoperatively KOOS PS.

CONCLUSIONS

The results of the present study show the systemic application of 1 g TXA reduces hemoglobin drop and postoperative morbidity (pain, intraarticular effusion, and ROM) after tibial open wedge HTO.

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.

A systematic review about telemedicine in orthopedics

PURPOSE

Until now, the use of telemedical applications in orthopedics was limited to sparsely populated countries. However, due to the SARS-CoV-2 pandemic, interest in orthopedics in these procedures has increased significantly. The aim of this systematic review was to find out to what extent there is scientific evidence for the use of telemedicine in the orthopedic field.

METHODS

A systematic literature search was carried out in various databases on randomized controlled trials (RCTs) on telemedical applications in orthopedics.

RESULTS

Altogether, 14 articles were identified that reported about a total of eight RCTs of telemedical applications in orthopedics. Two RCTs were about a patient-to-doctor video consultation and six RCTs were about telerehabilitation after knee and hip arthroplasty (4 × knee arthroplasty, one hip and knee arthroplasty, one hip arthroplasty). For the majority of outcome parameters evaluated, there were no significant differences between the study groups. The cost effectiveness of videoconsultations depended on the workload (number of patient consultations) as well as the effectiveness of telerehabilitation on the distance of the patient's home to the health care center (30 km round-trip).

CONCLUSION

There is sufficient evidence to recommend the use of telemedical methods in orthopedics. However, more research is necessary to further expand the possibilities of telemedical methods with regard to physical examination.

Concurrent validity of a patient self-administered examination and a clinical examination for femoroacetabular impingement syndrome

Objective

Telehealth has been established as a viable option for improved access and timeliness of care. Physician-guided patient self-evaluation may improve the viability of telehealth evaluation; however, there are little data evaluating the efficacy of self-administered examination (SAE). This study aims to compare the diagnostic accuracy of a patient SAE to a traditional standardised clinical examination (SCE) for evaluation of femoroacetabular impingement syndrome (FAIS).

Methods

75 patients seeking care for hip-related pain were included for participation. All patients underwent both SAE and SCE and were randomised to the order of the examinations. Diagnostic accuracy statistics were calculated for both examination group for a final diagnosis of FAIS. Mean diagnostic accuracy results for each group were then compared using Mann-Whitney U non-parametric tests.

Results

The diagnostic accuracy of individual SAE and SCE manoeuvres varied widely. Both SAE and SCE demonstrated no to moderate change in post-test probability for the diagnosis of FAIS. Although low, SAE demonstrated a statistically greater mean diagnostic accuracy compared with the SCE (53.6% vs 45.5%, p=0.02).

Conclusion

Diagnostic accuracy was statistically significantly higher for the self-exam than for the traditional clinical exam although the difference may not be clinically relevant. Although the mean accuracy remains relatively low for both exams, these values are consistent with hip exam for FAIS reported in the literature. Having established the validity of an SAE, future investigations will need to evaluate implementation in a telehealth setting.

Substitution of outpatient hospital care with specialist care in the primary care setting: A systematic review on quality of care, health and costs

RATIONALE, AIMS AND OBJECTIVE

Substituting outpatient hospital care with primary care is seen as a solution to decrease unnecessary referrals to outpatient hospital care and decrease rising healthcare costs. This systematic review aimed to evaluate the effects on quality of care, health and costs outcomes of substituting outpatient hospital care with primary care-based interventions, which are performed by medical specialists in face-to-face consultations in a primary care setting.

METHOD

The systematic review was performed using the PICO framework. Original papers in which the premise of the intervention was to substitute outpatient hospital care with primary care through the involvement of a medical specialist in a primary care setting were eligible.

RESULTS

A total of 14 papers were included. A substitution intervention in general practitioner (GP) practices was described in 11 papers, three described a joint consultation intervention in which GPs see patients together with a medical specialist. This study showed that substitution initiatives result mostly in favourable outcomes compared to outpatient hospital care. The initiatives resulted mostly in shorter waiting lists, shorter clinic waiting times and higher patient satisfaction. Costs for treating one extra patient seemed to be higher in the intervention settings. This was mainly caused by inefficient planning of consultation hours and lower patient numbers.

CONCLUSIONS

Despite the fact that internationally a lot has been written about the importance of performing substitution interventions in which preventing unnecessary referrals to outpatient hospital care was the aim, only 14 papers were included. Future systematic reviews should focus on the effects on the Triple Aim of substitution initiatives in which other healthcare professions than medical specialists are involved along with new technologies, such as e-consults. Additionally, to gain more insight into the effects of substitution initiatives operating in a dynamic healthcare context, it is important to keep evaluating the interventions in a longitudinal study design.

Telerheumatology: A Systematic Review

OBJECTIVE

To identify and summarize the published and gray literature on the use of telemedicine for the diagnosis and management of inflammatory and/or autoimmune rheumatic disease.

METHODS

We performed a registered systematic search (CRD42015025382) for studies using MEDLINE (1946 to July 2015), Embase (1974 to July 2015), Web of Science (1900 to July 2015), and Scopus (1946 to July 2015) databases. We included studies that demonstrated the use of telemedicine for diagnosis and/or management of inflammatory/autoimmune rheumatic disease. Following data extraction, we performed a descriptive analysis.

RESULTS

Our literature search identified 1,468 potentially eligible studies. Of these studies, 20 were ultimately included in this review. Studies varied significantly in publication type, quality of evidence, and the reporting of methods. Most demonstrated a high risk of bias. Rheumatoid arthritis was the most commonly studied rheumatic disease (42% of patients). Studies demonstrated conflicting results regarding the effectiveness of telemedicine (18 found it effective, 1 found it effective but possibly harmful, and 1 found it ineffective). A limited number of studies included some component of a cost analysis (n = 6; 16% of patients); all of these found telemedicine to be cost-effective.

CONCLUSION

Studies identified by this systematic review generally found telemedicine to be effective for the diagnosis and management of autoimmune/inflammatory rheumatic disease; however, there is limited evidence to support this conclusion. Further studies are needed to determine the best uses of telemedicine for the diagnosis and management of these conditions.

Improving risk management for violence in mental health services: a multimethods approach

Background

Mental health professionals increasingly carry out risk assessments to prevent future violence by their patients. However, there are problems with accuracy and these assessments do not always translate into successful risk management.

Objectives

Our aim was to improve the accuracy of assessment and identify risk factors that are causal to be targeted by clinicians to ensure good risk management. Our objectives were to investigate key risks at the population level, construct new static and dynamic instruments, test validity and construct new models of risk management using Bayesian networks.

Methods and results

We utilised existing data sets from two national and commissioned a survey to identify risk factors at the population level. We confirmed that certain mental health factors previously thought to convey risk were important in future assessments and excluded others from subsequent parts of the study. Using a first-episode psychosis cohort, we constructed a risk assessment instrument for men and women and showed important sex differences in pathways to violence. We included a 1-year follow-up of patients discharged from medium secure services and validated a previously developed risk assessment guide, the Medium Security Recidivism Assessment Guide (MSRAG). We found that it is essential to combine ratings from static instruments such as the MSRAG with dynamic risk factors. Static levels of risk have important modifying effects on dynamic risk factors for their effects on violence and we further demonstrated this using a sample of released prisoners to construct risk assessment instruments for violence, robbery, drugs and acquisitive convictions. We constructed a preliminary instrument including dynamic risk measures and validated this in a second large data set of released prisoners. Finally, we incorporated findings from the follow-up of psychiatric patients discharged from medium secure services and two samples of released prisoners to construct Bayesian models to guide clinicians in risk management.

Conclusions

Risk factors for violence identified at the population level, including paranoid delusions and anxiety disorder, should be integrated in risk assessments together with established high-risk psychiatric morbidity such as substance misuse and antisocial personality disorder. The incorporation of dynamic factors resulted in improved accuracy, especially when combined in assessments using actuarial measures to obtain levels of risk using static factors. It is important to continue developing dynamic risk and protective measures with the aim of identifying factors that are causally related to violence. Only causal factors should be targeted in violence prevention interventions. Bayesian networks show considerable promise in developing software for clinicians to identify targets for intervention in the field. The Bayesian models developed in this programme are at the prototypical stage and require further programmer development into applications for use on tablets. These should be further tested in the field and then compared with structured professional judgement in a randomised controlled trial in terms of their effectiveness in preventing future violence.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Development of a teleconsultation system for communication between physiotherapists concerning children with complex movement and postural disorders

We investigated whether a relatively low-cost, PC-based teleconsultation system could be used for inter-institutional communication about children with complex movement and postural disorders. Four paediatric physiotherapists in three different institutions participated. Both email and videoconferencing were tested. Videoconferencing was unsuccessful, as the low-bandwidth analogue lines, used by the majority of the therapists, made the quality of the realtime video-images very poor. However, email with attached video-recordings was successful and the therapists used the system to consult each other about 20 cases. The therapists regarded the system as effective in clinical practice. However, some improvements would be desirable, such as making the system quicker to use and reducing the number of technical errors. Nonetheless, structured communication between physicians about complex postural and movement disorders appears to be promising both for patient referral and for decisions concerning treatment.

Medical teleconsultation to general practitioners reduces the medical error vulnerability of internal medicine patients

BACKGROUND

e-Health strategies are supposed to improve the performance of national health systems. Medical teleconsultation (MT) is an important component of such e-Health strategies.

OBJECTIVES

The outcome of MT was evaluated with regard to the impact on the medical error vulnerability (MEV) of internal medicine patients.

METHODS

A team of internal medicine doctors plus a network of forty specialists was set-up in one health district belonging to a unified and universal national health system of a country of Western Europe, in order to provide free-of-charge MT to support general practitioners in solving internal medicine cases. In this observational study, the case series of 2013 is reviewed.

RESULTS

a) Only 21% of the MT fell short to the general practitioner's expectations about the case solving focus; b) throughout the medical care process of the patient, 49% of the cases met with one or more of the five MEVs, namely: 1) clinical test mishandling; 2) inaccurate differential diagnosis; 3) inadequate information flow between health providers at different levels of care (transition care); 4) poor coordination between health providers; and 5) poor reconciliation of medications or hazardous therapies. c) MT canceled or prevented MEVs in 56% and mitigate MEVs in 15% of the cases; d) MT canceled or prevented 85% of MEV caused by poor information exchange in transition care, therefore improving patient referral and counter-referral.

CONCLUSIONS

MT reduces MEV and therefore, whenever implemented to a large extent, may improve the quality of health care delivery and the performance of national health systems.

Interactive telemedicine: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.

OBJECTIVES

To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation).

SEARCH METHODS

We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions.

DATA COLLECTION AND ANALYSIS

For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.

MAIN RESULTS

We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.

AUTHORS' CONCLUSIONS

The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.

Interactive telemedicine: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.

OBJECTIVES

To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation).

SEARCH METHODS

We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions.

DATA COLLECTION AND ANALYSIS

For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.

MAIN RESULTS

We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.

AUTHORS' CONCLUSIONS

The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.

Efficiency, satisfaction, and costs for remote video visits following radical prostatectomy: a randomized controlled trial

BACKGROUND

Telemedicine in an ambulatory surgical population remains incompletely evaluated.

OBJECTIVE

To investigate patient encounters in the outpatient setting using video visit (VV) technology compared to traditional office visits (OVs).

DESIGN, SETTING, AND PARTICIPANTS

From June 2013 to March 2014, 55 prescreened men with a history of prostate cancer were prospectively randomized. VVs, with the patient at home or at work, were included in the outpatient clinic calendar of urologists.

INTERVENTION

Remote VV versus traditional OV.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

An equivalence analysis was used to assess the primary outcome, visit efficiency as measured by time studies. Secondary outcomes were patient/provider satisfaction and costs.

RESULTS AND LIMITATIONS

There were 28 VVs and 27 OVs. VVs were equivalent in efficiency to relative to OVs, as measured by patient-provider face time (mean 14.5 vs 14.3min; p=0.96), patient wait time (18.4 vs 13.0min; p=0.20), and total time devoted to care (17.9 vs 17.8min; p=0.97). There were no significant differences in patient perception of visit confidentiality, efficiency, education quality, or overall satisfaction. VVs incurred lower costs, including distance traveled (median 0 vs 95 miles), travel time (0 vs 95min), missed work (0 vs 1 d), and money spent on travel ($0 vs $48; all p<0.0001). There was a high level of urologist satisfaction for both VVs (88%) and OVs (90%). The major limitation was sample size.

CONCLUSIONS

VV in the ambulatory postprostatectomy setting may have a future role in health care delivery models. We found equivalent efficiency, similar satisfaction, but significantly reduced patient costs for VV compared to OV. Further prospective analyses are warranted.

PATIENT SUMMARY

Among men with surgically treated prostate cancer, we evaluated the utility of remote video visits compared to office visits for outpatient consultation with a urologist. Video visits were associated with equivalent efficiency, similar satisfaction, and significantly lower patient costs when compared to office visits. We conclude that video visits may have a future role in health care delivery models.

Telerheumatology: an idea whose time has come

Australia is a vast country with one-third of the population living outside capital cities. Providing specialist rheumatologist services to regional, rural and remote Australians has generally required expensive and time-consuming travel for the patient and/or specialist. As a result, access to specialist care for remote Australians is poor. Rheumatoid arthritis is a common disease, but like many rheumatic diseases, it is complex to treat. Time-dependent joint damage and disability occur unless best evidence care is implemented. The relatively poor access to rheumatologist care allotted to nonmetropolitan Australians therefore represents a significant cause of potentially preventable disability in Australia. Telehealth has the potential to improve access to specialist rheumatologists for patients with rheumatoid arthritis and other rheumatic diseases, thereby decreasing the burden of disability caused by these diseases. Advances in videoconferencing technology, the national broadband rollout and recent Federal government financial incentives have led to a heightened interest in exploring the use of this technology in Australian rheumatology practice. This review summarises the current evidence base, outlines telehealth's strengths and weaknesses in managing rheumatic disease, and discusses the technological, medicolegal and financial aspects of this model of care. A mixed model offering both face-to-face and virtual consultations appears to be the best option, as it can overcome the barriers to accessing care posed by distance while also mitigating the risks of virtual consultation.

Potential use of telemedicine to provide outpatient care for inflammatory bowel disease

OBJECTIVES

Patients with inflammatory bowel disease (IBD) often experience barriers to subspecialty access. We applied telemedicine, using a new computerized system called Collaborative Imaging, to resolve these barriers. We studied patients' experience and satisfaction, and clinic throughput.

METHODS

We performed a prospective randomized controlled pilot study at a Veterans Affairs hospital, assigning patients into two groups: telemedicine encounter, with the IBD specialist remotely located, and standard encounter. We assessed patient experience and measured differences in satisfaction as well as clinic metrics such as appointment duration, wait time, and throughput.

RESULTS

We enrolled 34 patients with Crohn's disease and ulcerative colitis who underwent 57 encounters in 9 months. Patients were mostly Caucasian men, with a mean age of 61 years. The two groups similarly rated as excellent their clinic experience and the major clinical satisfaction indices of attention to patient concerns, bedside manner, and perceived skill level of the doctor. The total clinic duration, wait time, and median number of patients per clinic were also similar. The fellow and subspecialist highly rated the technical and informational quality of the telemedicine sessions.

CONCLUSIONS

IBD outpatient service may be delivered via a novel telemedicine system. In this pilot study, we observed a high level of patient satisfaction similar to that achieved with a direct clinical encounter.

The determinants of the antibiotic resistance process

BACKGROUND

The use of antibiotic drugs triggers a complex interaction involving many biological, sociological, and psychological determinants. Resistance to antibiotics is a serious worldwide problem which is increasing and has implications for morbidity, mortality, and health care both in hospitals and in the community.

OBJECTIVES

To analyze current research on the determinants of antibiotic resistance and comprehensively review the main factors in the process of resistance in order to aid our understanding and assessment of this problem.

METHODS

We conducted a MedLine search using the key words "determinants", "antibiotic", and "antibiotic resistance" to identify publications between 1995 and 2007 on the determinants of antibiotic resistance. Publications that did not address the determinants of antibiotic resistance were excluded.

RESULTS

The process and determinants of antibiotic resistance are described, beginning with the development of antibiotics, resistance and the mechanisms of resistance, sociocultural determinants of resistance, the consequences of antibiotic resistance, and alternative measures proposed to combat antibiotic resistance.

CONCLUSIONS

Analysis of the published literature identified the main determinants of antibiotic resistance as irrational use of antibiotics in humans and animal species, insufficient patient education when antibiotics are prescribed, lack of guidelines for treatment and control of infections, lack of scientific information for physicians on the rational use of antibiotics, and lack of official government policy on the rational use of antibiotics in public and private hospitals.

Analgesic efficacy of etoricoxib in primary dysmenorrhea: results of a randomized, controlled trial

OBJECTIVE

To determine the efficacy of etoricoxib in the treatment of primary dysmenorrhea.

METHODS

Seventy-three women were randomly assigned to receive single oral doses of etoricoxib 120 mg, placebo, or naproxen sodium 550 mg at the onset of moderate to severe pain associated with menses. During 3 consecutive menstrual cycles in this double-blind, 3-period, crossover study, pain intensity and pain relief were assessed over the 24-hour period following dosing, and global ratings of therapy were made at 8 and 24 h after dosing. Tolerability was assessed by spontaneous reports of adverse experiences.

RESULTS

Etoricoxib 120 mg provided analgesic efficacy superior to placebo for the primary endpoint, total pain relief over 8 h (TOPAR8, p<0.001), and for all secondary endpoints (p<0.050). The analgesic effect of etoricoxib 120 mg over the first 8 h was similar to that of naproxen sodium 550 mg. All treatments were well tolerated.

CONCLUSIONS

Etoricoxib 120 mg provided rapid and sustained analgesia that was superior to placebo and similar to that of naproxen sodium 550 mg.

Why do telemedicine systems fail to normalize as stable models of service delivery?

Two groups independently carried out qualitative studies of the development, implementation and evaluation of telehealth systems and services in the UK. The data collected (in more than 600 discrete data collection episodes) included semistructured interviews, observations and documents. We conducted a conjoint reanalysis of the data. The objective was to identify the conditions which dispose a telehealth service to be successful or to fail. There appear to be four conditions necessary for a telemedicine system to stabilize and then normalize as a means of service delivery. When one or more is absent, failure can be expected. These conditions are often overlooked by local proponents of telemedicine, who seem to rely on demonstrations that the equipment works as the primary criterion of success.

Patient Followup After Radical Prostatectomy by Internet Medical File

PURPOSE

The development of the Internet and the need for regular followup of patients often living a long way from the hospital led us to develop a followup dossier for those with localized prostate cancer treated with laparoscopic radical prostatectomy.

MATERIALS AND METHODS

This feasibility study was based on 140 patients who agreed to test this system. The website was opened on a server specifically devoted to this project with all required computer security. The website is composed of pages comprising the hospital discharge summary, and operative and histology reports. A quality of life questionnaire based on the assessment of urinary continence and sex life, and a prostate specific antigen (PSA) assay form are also included.

RESULTS

The patient is able to enter his PSA data and complete the questionnaire at home. Results are then sent to the treating physician. A contact page allows the patient and physician to exchange information by text. Of these 100 patients 92 connected regularly to the site with a mean connection rate of 8 per patient (range 1 to 22). Of the patients 98% were satisfied with the various sections of the site, 95% were satisfied with the medical file, 11% noticed connection problems and 14% reported technical problems essentially attributable to incorrect PSA data entry or incorrect functioning of videos due to the absence of appropriate software.

CONCLUSIONS

This type of Internet medical service for patients who have undergone surgery requiring regular followup appears to be a useful approach for the future by allowing the maintenance of close contact between the patient and physicians, while avoiding problems related to hospital visits regardless of the patient place of residence. It also provides general practitioners with access to the patient file with patient permission.

Virtual outreach: economic evaluation of joint teleconsultations for patients referred by their general practitioner for a specialist opinion

OBJECTIVES

To test the hypotheses that, compared with conventional outpatient consultations, joint teleconsultation (virtual outreach) would incur no increased costs to the NHS, reduce costs to patients, and reduce absences from work by patients and their carers.

DESIGN

Cost consequences study alongside randomised controlled trial.

SETTING

Two hospitals in London and Shrewsbury and 29 general practices in inner London and Wales.

PARTICIPANTS

3170 patients identified; 2094 eligible for inclusion and willing to participate. 1051 randomised to virtual outreach and 1043 to standard outpatient appointments.

MAIN OUTCOME MEASURES

NHS costs, patient costs, health status (SF-12), time spent attending index consultation, patient satisfaction.

RESULTS

Overall six months costs were greater for the virtual outreach consultations ( pound 724 per patient) than for conventional outpatient appointments ( pound 625): difference in means pound 99 ($162; 138) (95% confidence interval pound 10 to pound 187, P=0.03). If the analysis is restricted to resource items deemed "attributable" to the index consultation, six month costs were still greater for virtual outreach: difference in means pound 108 ( pound 73 to pound 142, P < 0.0001). In both analyses the index consultation accounted for the excess cost. Savings to patients in terms of costs and time occurred in both centres: difference in mean total patient cost pound 8 ( pound 5 to pound 10, P < 0.0001). Loss of productive time was less in the virtual outreach group: difference in mean cost pound 11 ( pound 10 to pound 12, P < 0.0001).

CONCLUSION

The main hypothesis that virtual outreach would be cost neutral is rejected, but the hypotheses that costs to patients and losses in productivity would be lower are supported.

Adverse renal effects of anti-inflammatory agents: evaluation of selective and nonselective cyclooxygenase inhibitors

Conventional nonsteroidal anti-inflammatory drugs (NSAIDs), i.e. nonselective cyclooxygenase COX inhibitors have well-documented nephrotoxicity. Adverse renal effects occur because of inhibition of the synthesis of cyclooxygenase-derived prostaglandins which act to modulate pathologic processes that would normally impair various renal functions. The introduction of the selective COX-2 inhibitors raised hope that this class of drugs would reduce injury in both the gastrointestinal tract and the kidneys. Animal and human data, however, suggest that COX-2 synthesized prostaglandins are important in the modulation of renal physiology during adverse conditions. Hence, it appears that these drugs are equal in causing nephrotoxicity as the nonselective COX inhibitors.

Design and performance of a multicentre, randomized controlled trial of teleconsulting

We have designed and performed a multicentre, randomized controlled trial of teleconsulting. The trial investigated the effectiveness and cost implications in rural and inner-city settings of using videoconferencing as an alternative to general practitioner referral to a hospital specialist. The participating general practitioners referred a total of 3170 patients who satisfied the entry criteria. Of these, 1040 (33%) failed to provide consent or otherwise refused to participate in the trial. Of the patients recruited to the trial, a total of 1902 (91%) completed and returned the baseline questionnaire. Although the trial was successful in recruiting sufficient patients and in obtaining high questionnaire response rates, the findings will require careful interpretation to take account of the limits which the protocol placed on the ability of general practitioners to select patients for referral.

The benefits of a qualitative approach to telemedicine research

We used qualitative research to evaluate the experience of the participants in teleconsultations between primary and secondary care. Semistructured interviews were conducted with 15 hospital specialists, 24 general practitioners and 30 patients. Focus groups were also held with hospital specialists (two groups), general practitioners (six groups) and administrative staff (five groups). Sixty teleconsultations in six different specialties were video-recorded. Early findings show that the participants (hospital specialists, general practitioners and patients) had different perceptions of the same teleconsultations. Furthermore, the participants perceptions of consultations differed from those of the researchers.

Joint teleconsultations (virtual outreach) versus standard outpatient appointments for patients referred by their general practitioner for a specialist opinion: a randomised trial

BACKGROUND

The current model of general practitioner referral of patients to hospital specialists in the UK is sometimes associated with unnecessary duplication of investigations and treatments. We aimed to compare joint teleconsultations between general practitioners, specialists, and patients (virtual outreach) with standard outpatient referral.

METHODS

Virtual outreach services were established in London and Shrewsbury. The general practitioners referred 3170 patients, of whom 2094 consented to participate in the study and were eligible for inclusion. 1051 patients were randomly assigned virtual outreach, and 1043 standard outpatient appointments. We followed up the patients for 6 months after their index consultation. The primary outcome measure was the offer of a follow-up outpatient appointment. Analysis was by intention to treat.

FINDINGS

More patients in the virtual outreach group than the standard group were offered a follow-up appointment (502 [52%] vs 400 [41%], odds ratio 1.52 [95% CI 1.27-1.82], p<0.0001). Significant differences in effects were observed between the two sites (p=0.009) and across different specialties (p<0.0001). Virtual outreach increased the offers of follow-up appointments more in Shrewsbury than in London, and more in ear, nose, and throat surgery and orthopaedics than in the other specialties. Fewer tests and investigations were ordered in the virtual outreach group by an average of 0.79 per patient (0.37-1.21, p=0.0002). Patients' satisfaction (analysed per protocol) was greater after a virtual outreach consultation than after a standard outpatient consultation (mean difference 0.33 scale points [95% CI 0.23-0.43], p<0.0001), with no heterogeneity between specialties or sites.

INTERPRETATION

The trial showed that allocation of patients to virtual outreach consultations is variably associated with increased offers of follow-up appointments according to site and specialty, but leads to significant increases in patients' satisfaction and substantial reductions in tests and investigations. Efficient operation of such services will require appropriate selection of patients, significant service reorganisation, and provision of logistical support.