Social acceptance and population confidence in telehealth in Quebec

Feasibility, User Acceptance, and Outcomes of Using a Cancer Prehabilitation App for Exercise: Pilot Cohort Study

Background

The efficacy of cancer prehabilitation programs is supported by international reviews and meta-analyses. Technology has been deployed in cancer prehabilitation to address challenges such as access or limited resources. This study evaluated the feasibility, user acceptance, safety, and program outcomes of a newly developed mobile app for cancer prehabilitation. The app integrates with Singapore's existing health care mobile app, Health Buddy, and provides instructional videos for prescribed exercises.

Objective

The objectives of this study were to investigate the feasibility, user experience, safety, and outcomes of a mobile app for cancer prehabilitation within a hospital-associated, home-based, multimodal cancer prehabilitation program.

Methods

This retrospective study analyzed the records of patients enrolled in the cancer prehabilitation program from September 1, 2022, to March 30, 2023. Patients who participated in the prehabilitation program (n=63) were categorized into 2 groups: those prescribed the app (n=41) and those who were not (n=22). There was further subgroup analysis of those who were prescribed: app users (n=25) versus those who were non-app users (n=16). Demographics, Fried Frailty Phenotype, prehabilitation duration, app use, and functional outcome measures (6-minute walk test [6MWT], 30-second sit-to-stand test [STS], timed up and go test [TUG], and Hospital Anxiety and Depression Scale [HADS]) were collected. Compliance was determined by the completion of prescribed exercises and the accuracy of executing these exercises, with a high compliance rate considered to be at 80% or more. Baseline characteristics and preoperative outcomes were compared between the groups. User satisfaction was assessed through surveys among app users (n=25).

Results

Among 63 patients, 41 (65.1%) patients were prescribed the app, of which 22 (34.9%) patients were users. No significant differences in preoperative functional improvements were observed between app users and nonusers (6MWT: P=.60; STS: P=.81; TUG: P=.53; HADS: P=.36), or between those prescribed and not prescribed the app (6MWT: P=.94; STS: P=.26; TUG: P=.39; HADS: P=.62). However, high compliance rates (80%) were observed among app users. Patient satisfaction with the app was high (>90%), with positive feedback on ease of use and technical reliability. Baseline measures revealed significantly lower functional scores and higher mean frailty scores in the nonprescribed group.

Conclusions

This preliminary study demonstrates the acceptability, feasibility, and safety of Singapore's first smartphone app for exercise prescription in cancer prehabilitation. Lower baseline functional outcome measures and a higher mean frailty score in the unprescribed group have implications for the selection process and patient participation. Further studies should include strategies to enhance patients' readiness for technology, sustainability, and effectiveness in older patients.

Experience of a TelEmergency program in Colombia South America: descriptive observational study between 2019 and 2021

INTRODUCTION

Colombia has 50,912,429 inhabitants, but only 50-70% of the population can effectively access health care services. The emergency room (ER) is a main contributor to the in-hospital care system since up to half of the admissions come through it. Telemedicine has become a tool to facilitate effective access to health care services, improve the timeliness of care, reduce diagnostic variability, and reduce costs associated with health. The aim of this study is to describe the experience of a Distance Emergency Care Program through Telemedicine (TelEmergency) to improve specialist access for patients at the Emergency Room (ER) in low- and medium-level care hospitals in Colombia.

METHODS

An observational descriptive study of a cohort including 1,544 patients during the program's first two years was conducted. Descriptive statistics were used to analyze the available data. The data are presented with summarized statistics of sociodemographic, clinical, and patient-care variables.

RESULTS

The study included a total of 1,544 patients, and the majority were adults between 60 and 79 years of age (n = 491, 32%). More than half were men (n = 832, 54%), and 68% (n = 1,057) belonged to the contributory health care regime. The service was requested from 346 municipalities, 70% (n = 1,076) from intermediate and rural settings. The most common diagnoses were related to COVID-19 (n = 356, 22%), respiratory diseases (n = 217, 14%), and cardiovascular diseases (n = 162, 10%). We observed 44% (n = 681) of local admissions either under observation (n = 53, 3%) or hospitalization (n = 380, 24%), limiting the need for hospital transfers. Program operation data revealed that 50% (n = 799) of requests were answered within two hours by the medical staff. The initial diagnosis was modified in 7% (n = 119) of the patients after being evaluated by specialists at the TelEmergency program.

CONCLUSIONS

This study shows the operational data collected during the first two years after the implementation of the TelEmergency program in Colombia, the first of its kind in the country. Its implementation offered specialized timely management of patients at the ER in low- and medium-level care hospitals, where there is no availability of specialized doctors.

Feasibility indicators of telemedicine for patients with dementia in a public hospital in Northeast Brazil during the COVID-19 pandemic

Background

The use of telemedicine has become a fundamental tool in healthcare in recent years, especially at times of Covid-19 pandemic. Currently, there are several telemedicine tools that are simple, inexpensive, and effective means of communication. This article aims to describe indicators of feasibility including patient recruitment, attendance, discomfort (internet connection issues and/or noncompliant patient behavior), satisfaction, and travel time and cost savings of virtual telemedicine consultations for patients with dementia.

Methods

The study was conducted at the Geriatrics Department of Hospital Universitário Walter Cantídio (HUWC) in Fortaleza, Brazil, between May 1^st and December 31, 2020. The eligibility criteria included previous diagnosis of dementia syndrome and receiving care at the hospital’s dementia outpatient clinic in face-to-face consultations in the preceding 12 months. Patients were excluded if they did not feel comfortable with virtual consultations, did not have the required communication technology available or their caregiver was not available to attend the remote consultation. The patients were recruited from the outpatient dementia clinic’s medical appointment scheduling list. The intervention was designed as a one-time consultation and it included treatment approaches and health promotion recommendations.

Results

Patient recruitment, attendance and discomfort rates were 85.5%, 97.7% and 9.4%, respectively. To attend face-to-face visits, they reported an average travel time (including the consultation) of 233.21 minutes and average total cost of 60.61 reais (around USD 11). The study intervention was well accepted among the patients and their caregivers with 97.6% being satisfied. Many were happy to avoid long waits in crowded medical waiting rooms and the risk of covid-19 contagion.

Conclusions

We found good recruitment, attendance, and acceptance rates of remote care for the follow-up of dementia patients as well as low discomfort rates.

Trial registration

Brazilian Trial Registry (REBEC) RBR-9xs978.

Study protocol randomised controlled trial comparison of cost-utility and cost-effectiveness of a face-to-face rehabilitation programme versus a telemedicine programme in the treatment of patients with chronic low back pain

INTRODUCTION

Chronic lower back pain is a highly prevalent medical condition in Western countries, which that incurs a considerable social and economic burden. Although prescription exercise at home for chronic pain has become a widely used alternative to reduce healthcare costs, the evidence regarding patient adherence and decreased in costs in European countries is scarce and inconclusive. The objective of this study is to examine the cost-utility and cost-effectiveness in patients with chronic lower back pain treated with the McKenzie Method and electroanalgesia via a telemedicine programme versus a face-to-face programme.

METHODS AND ANALYSIS

This study reports the protocol for a randomised, two-arm, multicentre, parallel controlled trial. A total of 540 patients with chronic lower back pain (onset time ≥3 months, Roland Morris Disability Questionnaire ≥4) will be recruited in three hospitals in Andalusia. Participants will be assigned to one of two groups (n=270, respectively) to receive electroanalgesia and Mckenzie method exercises through a telemedicine or a face-to-face programme. A total of 24 sessions will be administered three times a week for 8 weeks. Since the study design does not allow participant blinding, the outcome assessor and the statistician will be blinded. Use of helth care resources and costs due to work absenteeism will be captured and analysed. In addition, pain, intensity, fear of movement, quality of life and strength of the core muscle and anteflexion lumbar will be recorded at 2 and 6 months after the start of treatment.

ETHICS AND DISSEMINATION

Human Research and Local Ethics Committee of the 'Hospital Complex Torrecárdenas of Almeria, University Hospital of Granada and Virgen Macarena de Sevilla Hospital-Andalusian Health Service'. Study findings will be released to the research, clinical and health service through publication in international journals and conferences.

TRIAL REGISTRATION NUMBER

NCT04266366.

Long-term cost-utility analysis of remote monitoring of older patients with pacemakers: the PONIENTE study

Background

Cost-effectiveness studies on pacemakers have increased in the last years. However the number of long-term cost-utility studies is limited. The objective of this study was to perform a cost-utility analysis comparing remote monitoring (RM) versus conventional monitoring (CM) in hospital of older patients with pacemakers, 5 years after implant.

Methods

Under a controlled, not randomized, nor masked clinical trial, 83 patients with pacemakers were initially selected. After five years of follow-up, a total of 55 patients (CM = 34; RM = 21) completed the study. A cost-utility analysis of RM in terms of costs per gained quality-adjusted life years (QALYs) was conducted. The costs from the Public Health System (PHS) as well as patients and their relatives were taken into account for the study. The robustness of the results was verified by the probabilistic analyses through Monte-Carlo simulations.

Results

After a five-year follow-up period, total costs were lower in the RM group by 23.02% than in the CM group (€274.52 versus €356.62; p = 0.033) because of a cost saving from patients’ perspective (€59.05 versus €102.98; p = 0.002). However, the reduction of in-hospital visits derived from RM exhibited insignificant impact on the costs from the PHS perspective, with a cost saving of 15.04% (€215.48 vs. €253.64; p = 0.144). Costs/QALYs obtained by the RM group were higher as compared to the CM group, although there were no significant differences. The incremental cost-effectiveness ratio of CM in comparison to RM became positive (€301.16).

Conclusions

This study confirms RM of older patients with pacemakers appears still as a cost-utility alternative to CM in hospital after 5 years of follow-up.

Trial registration

ClinicalTrials.gov: (Identifier: NCT02234245). Registered 09 September 2014 - Prospectively registered.

[Beyond benefit evaluation: Considering the unintended consequences of telehealth]

La télésanté est considérée comme un levier incontournable dans les choix des politiques en santé. Toutefois, il subsiste de nombreux enjeux face à son intégration réussie dans les pratiques cliniques. À ce jour, un grand nombre d’initiatives en télésanté peine à dépasser le stade de projet pilote. Cette situation s’explique en partie par une culture de l’innovation qui est principalement focalisée sur les bénéfices attendus de la technologie et moins sur les changements et les transformations qu’elle peut entraîner. La télésanté est utilisée dans des établissements de santé dont la dynamique sociale est pour le moins complexe. Son introduction entraîne des conséquences inattendues pouvant affecter aussi bien les patients, les communautés, les professionnels, les établissements que les systèmes de santé et la société dans son ensemble. L’objectif de cet article est de discuter de certaines des conséquences inattendues découlant de l’utilisation de la télésanté dans les établissements et systèmes de santé.

Artificial Intelligence and Health Technology Assessment: Anticipating a New Level of Complexity

Artificial intelligence (AI) is seen as a strategic lever to improve access, quality, and efficiency of care and services and to build learning and value-based health systems. Many studies have examined the technical performance of AI within an experimental context. These studies provide limited insights into the issues that its use in a real-world context of care and services raises. To help decision makers address these issues in a systemic and holistic manner, this viewpoint paper relies on the health technology assessment core model to contrast the expectations of the health sector toward the use of AI with the risks that should be mitigated for its responsible deployment. The analysis adopts the perspective of payers (ie, health system organizations and agencies) because of their central role in regulating, financing, and reimbursing novel technologies. This paper suggests that AI-based systems should be seen as a health system transformation lever, rather than a discrete set of technological devices. Their use could bring significant changes and impacts at several levels: technological, clinical, human and cognitive (patient and clinician), professional and organizational, economic, legal, and ethical. The assessment of AI's value proposition should thus go beyond technical performance and cost logic by performing a holistic analysis of its value in a real-world context of care and services. To guide AI development, generate knowledge, and draw lessons that can be translated into action, the right political, regulatory, organizational, clinical, and technological conditions for innovation should be created as a first step.

The Lean and Agile Multi-dimensional Process (LAMP) - a new framework for rapid and iterative evidence generation to support health-care technology design and development

Introduction: Health technology assessments (HTA) are tools for policymaking and resource allocation. Early HTAs are increasingly used in design and development of new technologies. Conducting early HTAs is challenging, due to a lack of evidence and significant uncertainties in the technology and the market. A multi-disciplinary approach is considered essential. However, an operational framework that can enable the integration of multi-dimensional evidence into commercialization remains lacking.Areas covered: We developed the Lean and Agile Multi-dimensional Process (LAMP), an early HTA framework, for embedding commercial decision-making in structured evidence generation activities, divided into phases. Diverse evidence in unmet needs, user acceptance, cost-effectiveness, and market competitiveness are being generated in increasing depth. This supports the emergence of design and value propositions that align technology capabilities and clinical and user needs.Expert opinion: We have been applying LAMP to working with medical device and diagnostic industry in the UK. The framework can be adapted to suit different technologies, decision needs, time scales, and resources. LAMP offers a practical solution to the multi-disciplinary approach. Methodologists drive the process by performing evidence generation and synthesis as and by enabling interactions between manufacturers, designers, clinicians, and other key stakeholders.

[Organizational and systemic conditions of citizen-patient involvement in the development of telehealth in Quebec]

OBJECTIVES

Involving citizens-patients in decisions regarding telehealth services could allow a better match between the services offered and the needs and contexts of individuals and communities. This study aims to explore the organizational and systemic conditions that can influence citizen-patient involvement in the development of telehealth in Quebec.

METHODS

A qualitative study based on semi-structured interviews with 29 key informants was conducted. A deductive-inductive thematic analysis was performed based on an integrative framework derived from diffusion of innovation theories.

RESULTS

Citizen-patient involvement in the development of telehealth remains dependent on many organizational and systemic conditions. At the organizational level, it could affect the dynamics, process, cultures, rules and operations in organizations; hence the needs for adequate human and material resources as well as the availability of support for change. At the systemic level, the ideology, the sociopolitical context and the decisions in favor (or not) of a citizen appropriation of the decision-making are central. Concerns about scientific evidence, training, as well as the roles of professional federations, and citizen-patient groups have also emerged. Organizational and systemic levels are interdependent.

CONCLUSION

The organizational and systemic contexts may explain part of the contrast between the discourse in favor of citizen-patient involvement in telehealth decision-making and the reality observed in Quebec. This study provides a basis for analyzing citizen-patient involvement in services development from the perspective of organizational and systemic changes.

A Digital Game and School-Based Intervention for Students in Hong Kong: Quasi-Experimental Design

Background

In Hong Kong, with an increasing number of children experiencing mental health issues, there is a need to not only develop innovative interventions but also develop comprehensive prevention interventions so as to reduce their anxiety symptoms and enhance their emotional management and interpersonal relationships.

Objective

The aim of this study was to determine the effectiveness of The Adventures of DoReMiFa, an integration model of the cognitive-behavioral approach and positive psychology by using digital game–based and school-based mental health enhancement intervention to magnify the social and emotional health and well-being of the school children in Hong Kong aged 9 to 11 years.

Methods

A quasi-experimental design method was used to evaluate this digital game and school-based intervention. The Adventures of DoReMiFa was piloted in 4 primary schools where students were allocated to either an intervention or a control group. The participants were assessed at pre- and postintervention with a 6-month follow-up measuring their mental health knowledge, levels of anxiety symptoms, positive and negative thinking, perspective-taking, and self-esteem.

Results

A total of 459 primary school students from 4 primary schools participated in the study. The response rate on the questionnaires answered on the Web was up to 85.1% (391/459). Compared with the control group, the intervention group was found to have significant association with improved mental health knowledge at the time immediately after the intervention (beta=.46; P=.01) and in the 6-month postintervention period (beta=.66; P<.001); for perspective-taking, the intervention group had exhibited a significant improvement 6 months after the completion of the universal program (beta=1.50; P=.03). The intervention, however, was found not to be effective in reducing the rates of anxiety symptoms and negative thinking among the participating students.

Conclusions

The Adventures of DoReMiFa, an integration of a digital game–based and school-based mental health enhancement intervention, was shown to be effective in elevating the knowledge of mental health and promoting perspective-taking in the primary school students of Hong Kong. Although there was insufficient evidence to support a reduction in symptoms of anxiety and negative automatic thoughts, the overall results were still encouraging in that a preventive effect was found, indicating that the program has the potential to enhance the mental well-being of schoolchildren. It also suggests that knowledge enhancement may not necessarily lead to behavior change, and more focused effort may be needed to achieve the translation. The implications and limitations of this study and suggestions for future research were also discussed.

A discrete choice experiment on preferences of patients with low back pain about non-surgical treatments: identification, refinement and selection of attributes and levels

Objectives: Hospital-based health technology assessment (HB-HTA) needs to consider all relevant data to help decision making, including patients' preferences. In this study, we comprehensively describe the process of identification, refinement and selection of attributes and levels for a discrete choice experiment (DCE). Methods: A mixed-methods design was used to identify attributes and levels explaining low back pain (LBP) patients' choice for a non-surgical treatment. This design combined a systematic literature review with a patients' focus group, one-on-one interactions with experts and patients, and discussions with stakeholder committee members. Following the patient's focus group, preference exercises were conducted. A consensus about the attributes and levels was researched during discussions with committee members. Results: The literature review yielded 40 attributes to consider in patients' treatment choice. During the focus group, one additional attribute emerged. The preference exercises allowed selecting eight attributes for the DCE. These eight attributes and their levels were discussed and validated by the committee members who helped reframe two levels in one of the attributes and delete one attribute. The final seven attributes were: treatment modality, pain reduction, onset of treatment efficacy, duration of efficacy, difficulty in daily living activities, sleep problem, and knowledge about their body and pain. Conclusion: This study is one of the few to comprehensively describe the selection process of attributes and levels for a DCE. This may help ensure transparency and judge the quality of the decision-making process. In the context of a HB-HTA unit, this strengthens the legitimacy to perform a DCE to better inform decision makers in a patient-centered care approach.

Involving Citizen-Patients in the Development of Telehealth Services: Qualitative Study of Experts' and Citizen-Patients' Perspectives

Background

Decisions regarding telehealth services in Quebec (Canada) have been largely technocratic by nature for the last 15 years, and the involvement of citizen-patients in the development of telehealth services is virtually nonexistent. In view of the societal challenges that telehealth raises, citizen-patient involvement could ensure more balance between evidence from traditional research methodologies and technical experts and the needs and expectations of populations in decisions about telehealth services.

Objective

This study aimed to explore the perception of various stakeholders (decision makers, telehealth program and policy managers, clinicians, researchers, evaluators, and citizen-patients) regarding the involvement of citizen-patients in the development of telehealth services in Quebec. In particular, we explored its potential advantages, added value, obstacles, and challenges it raises for decision making.

Methods

We used a qualitative research approach based on semistructured individual interviews, with a total of 29 key actors. Respondents were identified by the contact network method. Interviews were recorded and transcribed verbatim. A pragmatic content thematic analysis was performed. To increase the capacity for interpretation and analysis, we were guided by the principle of data triangulation.

Results

Citizen-patient involvement in decision making is perceived more as a theoretical idea than as a practical reality in health care organizations or in the health system. There is very little connection between citizen involvement structures or patient and user groups and telehealth leaders. For the respondents, citizen-patient involvement in telehealth could increase the accountability and transparency of decision making and make it more pragmatic within an innovation-driven health system. This involvement could also make citizen-patients ambassadors and promoters of telehealth and improve the quality and organization of health services while ensuring they are more socially relevant. Challenges and constraints that were reported include the ambiguity of the citizen-patient, who should be involved and how, claimant citizen-patient, the risk of professionalization of citizen-patient involvement, and the gap between decision time versus time to involve the citizen-patient.

Conclusions

This study provides a basis for future research on the potential of involving citizen-patients in telehealth. There is a great need for research on the issue of citizen-patient involvement as an organizational innovation (in terms of decision-making model). Research on the organizational predisposition and preparation for such a change becomes central. More efforts to synthesize and translate knowledge on public participation in decision making in the health sector, particularly in the field of technology development, are needed.

Web-Based Physical Activity Intervention for Latina Adolescents: Feasibility, Acceptability, and Potential Efficacy of the Niñas Saludables Study

BACKGROUND

Physical activity is markedly low in Latina adolescents, yet few physical activity interventions have been attempted in this population. Web-based interventions can incorporate theory-based components, be appealing to adolescents, and have potential for low-cost dissemination.

OBJECTIVE

This study aimed to assess the feasibility, acceptability, and potential efficacy of a Web-based physical activity intervention for Latina adolescents in a single-arm pilot trial.

METHODS

A total of 21 Latina adolescents (aged 12-18 years) who could read and write in English and were underactive (<90 min/week) participated in a 12-week, theory-informed Web-based physical activity intervention. The intervention website was modified from a previous Web-based intervention for Latina adults. Web content was individually tailored based on the responses to monthly questionnaires. Feasibility was measured by recruitment, retention, and adherence/engagement, and acceptability was measured by satisfaction surveys. Physical activity was measured at baseline and follow-up (12 weeks) using the 7-day physical activity recall (PAR) interview and accelerometers.

RESULTS

Baseline activity as measured by the 7-day PAR and accelerometers was 24.7 (SD 26.11) and 24.8 (SD 38.3) min/week, respectively. At 12 weeks, 19 participants (90%, 19/21) returned. Adherence and engagement with materials were low, but 72% (15/21) of the participants indicated that they were satisfied with the intervention. Activity at 12 weeks increased by 58.8 (SD 11.33) min/week measured by the 7-day PAR (P<.001). Accelerometer-measured activity did not increase. Activities reported at follow-up were more varied than at baseline, including some activities measured poorly by accelerometers (eg, biking and swimming). Participants suggested simplifying the website and incorporating other technologies.

CONCLUSIONS

Good retention and increases in self-reported activity suggest a promising approach to delivering a physical activity intervention to Latina adolescents. Incorporating other technologies, such as smartphone apps, could make the intervention more engaging, acceptable, and effective.

Telephone consultation in primary care

Purpose

The purpose of this paper is to describe and analyze a teleconsultation modality based on a simple telephone call, using either landline or mobile phone, made available to more than two million people. Telecommunication systems are an increasingly common feature in modern healthcare. However, making teleconsultations available to the entire population covered by a public health system is a challenging goal.

Design/methodology/approach

This retrospective longitudinal observational study analyzed how this modality was used at the primary care level in Galicia, a region in the Northwest of Spain, in 2014 and 2015, focusing on demand, gender and age preferences, rural vs urban population and efficiency.

Findings

Of 28,472,852 consultations requested in this period, 9.0 percent were telephone consultations. Women requested more telephone consultations (9.9 percent of total consultations) than men (7.7 percent of total consultations). The highest demand occurred for the over 85 age group for both men and women. In both years, 2014 and 2015, the number of telephone consultations per inhabitant was higher in urban (0.53 and 0.69) than in rural areas (0.34 and 0.47). In 10.9 percent of cases, the telephone consultations required further face-to-face consultation.

Originality/value

Conventional voice telephone calls can efficiently replace conventional face-to-face consultations in primary healthcare in roughly 10 percent of cases. Women are more likely than men to use primary care services in both face-to-face and telephone consultation modalities. Public healthcare systems should consider implementing telephone consultations to deliver their services.

Assessing Feasibility and Acceptability of Web-Based Enhanced Relapse Prevention for Bipolar Disorder (ERPonline): A Randomized Controlled Trial

Background

Interventions that teach people with bipolar disorder (BD) to recognize and respond to early warning signs (EWS) of relapse are recommended but implementation in clinical practice is poor.

Objectives

The objective of this study was to test the feasibility and acceptability of a randomized controlled trial (RCT) to evaluate a Web-based enhanced relapse prevention intervention (ERPonline) and to report preliminary evidence of effectiveness.

Methods

A single-blind, parallel, primarily online RCT (n=96) over 48 weeks comparing ERPonline plus usual treatment with “waitlist (WL) control” plus usual treatment for people with BD recruited through National Health Services (NHSs), voluntary organizations, and media. Randomization was independent, minimized on number of previous episodes (<8, 8-20, 21+). Primary outcomes were recruitment and retention rates, levels of intervention use, adverse events, and participant feedback. Process and clinical outcomes were assessed by telephone and Web and compared using linear models with intention-to-treat analysis.

Results

A total of 280 people registered interest online, from which 96 met inclusion criteria, consented, and were randomized (49 to WL, 47 to ERPonline) over 17 months, with 80% retention in telephone and online follow-up at all time points, except at week 48 (76%). Acceptability was high for both ERPonline and trial methods. ERPonline cost approximately £19,340 to create, and £2176 per year to host and maintain the site. Qualitative data highlighted the importance of the relationship that the users have with Web-based interventions. Differences between the group means suggested that access to ERPonline was associated with: a more positive model of BD at 24 weeks (10.70, 95% CI 0.90 to 20.5) and 48 weeks (13.1, 95% CI 2.44 to 23.93); increased monitoring of EWS of depression at 48 weeks (−1.39, 95% CI −2.61 to −0.163) and of hypomania at 24 weeks (−1.72, 95% CI −2.98 to −0.47) and 48 weeks (−1.61, 95% CI −2.92 to −0.30), compared with WL. There was no evidence of impact of ERPonline on clinical outcomes or medication adherence, but relapse rates across both arms were low (15%) and the sample remained high functioning throughout. One person died by suicide before randomization and 5 people in ERPonline and 6 in WL reported ideas of suicide or self-harm. None were deemed study related by an independent Trial Steering Committee (TSC).

Conclusions

ERPonline offers a cheap accessible option for people seeking ongoing support following successful treatment. However, given high functioning and low relapse rates in this study, testing clinical effectiveness for this population would require very large sample sizes. Building in human support to use ERPonline should be considered.

Trial registration

International Standard Randomized Controlled Trial Number (ISRCTN): 56908625; http://www.isrctn.com/ISRCTN56908625 (Archived by WebCite at http://www.webcitation.org/6of1ON2S0)

A Comparison of Web and Telephone Responses From a National HIV and AIDS Survey

BACKGROUND

Response differences to survey questions are known to exist for different modes of questionnaire completion. Previous research has shown that response differences by mode are larger for sensitive and complicated questions. However, it is unknown what effect completion mode may have on HIV and AIDS survey research, which addresses particularly sensitive and stigmatized health issues.

OBJECTIVES

We seek to compare responses between self-selected Web and telephone respondents in terms of social desirability and item nonresponse in a national HIV and AIDS survey.

METHODS

A survey of 2085 people in Canada aged 18 years and older was conducted to explore public knowledge, attitudes, and behaviors around HIV and AIDS in May 2011. Participants were recruited using random-digit dialing and could select to be interviewed on the telephone or self-complete through the Internet. For this paper, 15 questions considered to be either sensitive, stigma-related, or less-sensitive in nature were assessed to estimate associations between responses and mode of completion. Multivariate regression analyses were conducted for questions with significant (P≤.05) bivariate differences in responses to adjust for sociodemographic factors. As survey mode was not randomly assigned, we created a propensity score variable and included it in our multivariate models to control for mode selection bias.

RESULTS

A total of 81% of participants completed the questionnaire through the Internet, and 19% completed by telephone. Telephone respondents were older, reported less education, had lower incomes, and were more likely from the province of Quebec. Overall, 2 of 13 questions assessed for social desirability and 3 of 15 questions assessed for item nonresponse were significantly associated with choice of mode in the multivariate analysis. For social desirability, Web respondents were more likely than telephone respondents to report more than 1 sexual partner in the past year (fully adjusted odds ratio (OR)=3.65, 95% CI 1.80-7.42) and more likely to have donated to charity in the past year (OR=1.63, 95% CI 1.15-2.29). For item nonresponse, Web respondents were more likely than telephone respondents to have a missing or "don't know" response when asked about: the disease they were most concerned about (OR=3.02, 95% CI 1.67-5.47); if they had ever been tested for HIV (OR=8.04, 95% CI 2.46-26.31); and when rating their level of comfort with shopping at grocery store if the owner was known to have HIV or AIDS (OR=3.11, 95% CI 1.47-6.63).

CONCLUSION

Sociodemographic differences existed between Web and telephone respondents, but for 23 of 28 questions considered in our analysis, there were no significant differences in responses by mode. For surveys with very sensitive health content, such as HIV and AIDS, Web administration may be subject to less social desirability bias but may also have greater item nonresponse for certain questions.

Acceptability, Feasibility, and Cost of Telemedicine for Nonacute Headaches: A Randomized Study Comparing Video and Traditional Consultations

Background

The feasibility of telemedicine in diagnosing and treating nonacute headaches, such as primary headaches (migraine and tension-type) and medication-overuse headaches has not been previously investigated. By eliminating the need of travel to specialists, telemedicine may offer significant time and money savings.

Objectives

Our objective was to estimate the acceptance of telemedicine and investigate the feasibility and cost savings of telemedicine consultations in diagnosing and treating nonacute headaches.

Methods

From September 2012 to March 2015, nonacute headache patients from Northern Norway who were referred to neurologists through an electronic application system were consecutively screened and randomized to participate in either telemedicine or traditional specialist visits. All patients were consulted by two neurologists at the neurological department in Tromsø University Hospital. Feasibility outcomes were compared between telemedicine and traditional groups. Baseline characteristics and costs were then compared between rural and urban patients. Travel costs were calculated by using the probabilistic method of the Norwegian traveling agency: the cheapest means of public transport for each study participant. Loss of pay was calculated based on the Norwegian full-time employee’s average salary: < 3.5 hours=a half day’s salary, > 3.5 hours spent on travel and consultation=one day’s salary. Distance and time spent on travel were estimated by using Google Maps.

Results

Of 557 headache patients screened, 479 were found eligible and 402 accepted telemedicine participation (83.9%, 402/479) and were included in the final analyses. Of these, 202 received traditional specialist consultations and 200 received telemedicine. All patients in the telemedicine group were satisfied with the video quality, and 198 (99%, 198/200) were satisfied with the sound quality. The baseline characteristics as well as headache diagnostics and follow-up appointments, and the investigation, advice, and prescription practices were not statistically different between the two randomized groups. In addition, telemedicine consultations were shorter than traditional visits (38.8 vs 43.7 min, P<.001).

The travel cost per rural individual (292/402, 73%) was €249, and estimated lost income was €234 per visit. The travel cost in the urban area (110/402, 27%) was €6, and estimated lost income was €117 per visit. The median traveling distance for rural patients was 526 km (range 1892 km), and the median traveling time was 7.8 hours (range 27.3 hours). Rural patients had a longer waiting time than urban patients (64 vs 47 days, P=.001), and fewer women were referred from rural areas (P=.04). Rural women reported higher pain scores than urban women (P=.005).

Conclusion

Our study shows that telemedicine is an accepted, feasible, time-saving, and cost-saving alternative to traditional specialist consultations for nonacute headaches.

Trial Registration

Clinicaltrials.gov NCT02270177; http://clinicaltrials.gov/ct2/show/NCT02270177 (Archived by WebCite at http://www.webcitation.org/6hmoHGo9Q)