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Nadkarni A, Garg A, Agrawal R, Sambari S, Mirchandani K, Velleman R, Gupta D, Bhatia U, Fernandes G, D’souza E, Amonkar A, Rane A. Acceptability and feasibility of assisted telepsychiatry in routine healthcare settings in India: a qualitative study. OXFORD OPEN DIGITAL HEALTH 2023; 1:oqad016. [PMID: 38025140 PMCID: PMC10668329 DOI: 10.1093/oodh/oqad016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/16/2023] [Accepted: 10/03/2023] [Indexed: 12/01/2023]
Abstract
Technology-enabled interventions are often recommended to overcome geographical barriers to access and inequitable distribution of mental healthcare workers. The aim of this study was to examine the acceptability and feasibility of an assisted telepsychiatry model implemented in primary care settings in India. In-depth interviews were conducted with patients who received telepsychiatry consultations. Data were collected about domains such as experience with communicating with psychiatrists over a video call and feasibility of accessing services. Data were analysed using a thematic analysis approach. Patients recognized that technology enabled them to access treatment and appreciated its contribution to the improvement in their mental health condition. They reported that the telepsychiatry experience was comparable to face-to-face consultations. They had a positive experience of facilitation by counsellors and found treatment delivery in primary care non-stigmatizing. While some adapted easily to the technology platform because of increased access to technology in their daily lives, others struggled to communicate over a screen. For some, availability of care closer to their homes was convenient; for others, even the little travel involved posed a financial burden. In some cases, the internet connectivity was poor and interfered with the video calls. Patients believed that scale could be achieved through adoption of this model by the public sector, collaboration with civil society, enhanced demand generation strategies and leveraging platforms beyond health systems. Assisted telepsychiatry integrated in routine healthcare settings has the potential to make scarce specialist mental health services accessible in low resource settings by overcoming geographical and logistical barriers.
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Affiliation(s)
- Abhijit Nadkarni
- Centre for Global Mental Health, Department of Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK
- Addictions and Related Research Group, Sangath, Porvorim, Goa 403501, India
| | - Ankur Garg
- Addictions and Related Research Group, Sangath, Porvorim, Goa 403501, India
| | - Ravindra Agrawal
- Addictions and Related Research Group, Sangath, Porvorim, Goa 403501, India
| | - Seema Sambari
- Addictions and Related Research Group, Sangath, Porvorim, Goa 403501, India
| | - Kedar Mirchandani
- Addictions and Related Research Group, Sangath, Porvorim, Goa 403501, India
| | - Richard Velleman
- Addictions and Related Research Group, Sangath, Porvorim, Goa 403501, India
- Department of Psychology, University of Bath, Claverton Down, Bath BA2 7AY, UK
| | - Devika Gupta
- Addictions and Related Research Group, Sangath, Porvorim, Goa 403501, India
| | - Urvita Bhatia
- Addictions and Related Research Group, Sangath, Porvorim, Goa 403501, India
| | - Godwin Fernandes
- Addictions and Related Research Group, Sangath, Porvorim, Goa 403501, India
| | - Ethel D’souza
- Addictions and Related Research Group, Sangath, Porvorim, Goa 403501, India
| | - Akshada Amonkar
- Addictions and Related Research Group, Sangath, Porvorim, Goa 403501, India
| | - Anil Rane
- Institute of Psychiatry & Human Behaviour , Bambolim, Goa 403108, India
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Grandhi TSP, Fontalis A, Raj RD, Kim WJ, Giebaly DE, Haddad FS. Telehealth for a better service delivery in orthopaedic surgery. Bone Joint J 2023; 105-B:843-849. [PMID: 37524357 DOI: 10.1302/0301-620x.105b8.bjj-2023-0089.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
Telehealth has the potential to change the way we approach patient care. From virtual consenting to reducing carbon emissions, costs, and waiting times, it is a powerful tool in our clinical armamentarium. There is mounting evidence that remote diagnostic evaluation and decision-making have reached an acceptable level of accuracy and can safely be adopted in orthopaedic surgery. Furthermore, patients' and surgeons' satisfaction with virtual appointments are comparable to in-person consultations. Challenges to the widespread use of telehealth should, however, be acknowledged and include the cost of installation, training, maintenance, and accessibility. It is also vital that clinicians are conscious of the medicolegal and ethical considerations surrounding the medium and adhere strictly to the relevant data protection legislation and storage framework. It remains to be seen how organizations harness the full spectrum of the technology to facilitate effective patient care.
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Affiliation(s)
- Tarani S P Grandhi
- Department of Trauma & Orthopaedics, University College London Hospitals, London, UK
| | - Andreas Fontalis
- Department of Trauma & Orthopaedics, University College London Hospitals, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Rhody D Raj
- Department of Trauma & Orthopaedics, University College London Hospitals, London, UK
| | - Woo J Kim
- Department of Trauma & Orthopaedics, University College London Hospitals, London, UK
| | - Dia E Giebaly
- Department of Trauma & Orthopaedics, University College London Hospitals, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Fares S Haddad
- Department of Trauma & Orthopaedics, University College London Hospitals, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
- The Bone & Joint Journal , London, UK
- The NIHR Biomedical Research Centre at UCLH, London, UK
- Princess Grace Hospital, London, UK
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Pokhilenko I, Janssen LMM, Paulus ATG, Drost RMWA, Hollingworth W, Thorn JC, Noble S, Simon J, Fischer C, Mayer S, Salvador-Carulla L, Konnopka A, Hakkaart van Roijen L, Brodszky V, Park AL, Evers SMAA. Development of an Instrument for the Assessment of Health-Related Multi-sectoral Resource Use in Europe: The PECUNIA RUM. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:155-166. [PMID: 36622541 PMCID: PMC9931843 DOI: 10.1007/s40258-022-00780-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/27/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Measuring objective resource-use quantities is important for generating valid cost estimates in economic evaluations. In the absence of acknowledged guidelines, measurement methods are often chosen based on practicality rather than methodological evidence. Furthermore, few resource-use measurement (RUM) instruments focus on the measurement of resource use in multiple societal sectors and their development process is rarely described. Thorn and colleagues proposed a stepwise approach to the development of RUM instruments, which has been used for developing cost questionnaires for specific trials. However, it remains unclear how this approach can be translated into practice and whether it is applicable to the development of generic self-reported RUM instruments and instruments measuring resource use in multiple sectors. This study provides a detailed description of the practical application of this stepwise approach to the development of a multi-sectoral RUM instrument developed within the ProgrammE in Costing, resource use measurement and outcome valuation for Use in multi-sectoral National and International health economic evaluAtions (PECUNIA) project. METHODS For the development of the PECUNIA RUM, the methodological approach was based on best practice guidelines. The process included six steps, including the definition of the instrument attributes, identification of cost-driving elements in each sector, review of methodological literature and development of a harmonized cross-sectorial approach, development of questionnaire modules and their subsequent harmonization. RESULTS The selected development approach was, overall, applicable to the development of the PECUNIA RUM. However, due to the complexity of the development of a multi-sectoral RUM instrument, additional steps such as establishing a uniform methodological basis, harmonization of questionnaire modules and involvement of a broader range of stakeholders (healthcare professionals, sector-specific experts, health economists) were needed. CONCLUSION This is the first study that transparently describes the development process of a generic multi-sectoral RUM instrument in health economics and provides insights into the methodological aspects and overall validity of its development process.
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Affiliation(s)
- Irina Pokhilenko
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, The Netherlands.
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
| | - Luca M M Janssen
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, The Netherlands
| | - Aggie T G Paulus
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, The Netherlands
- School of Health Professions Education (SHE), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, The Netherlands
| | - Ruben M W A Drost
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, The Netherlands
| | - William Hollingworth
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Joanna C Thorn
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Noble
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Judit Simon
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Claudia Fischer
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Susanne Mayer
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Luis Salvador-Carulla
- Mental Health Policy Unit, Faculty of Health, Health Research Institute, University of Canberra, Canberra, ACT, Australia
- School of Public Health, Menzies Centre for Health Policy, University of Sydney, Sydney, NSW, Australia
| | - Alexander Konnopka
- Department of Health Economics and Health Services Research, University Medical Center Hamburg, Hamburg, Germany
| | - Leona Hakkaart van Roijen
- Erasmus School of Health Policy and Management, Erasmus University of Rotterdam, Rotterdam, The Netherlands
| | - Valentin Brodszky
- Department of Health Policy, Corvinus University of Budapest, Budapest, Hungary
| | - A-La Park
- Department of Health Policy, Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Silvia M A A Evers
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, The Netherlands
- Trimbos Institute National Institute of Mental Health and Addiction, Utrecht, The Netherlands
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Melian C, Kieser D, Frampton C, C Wyatt M. Teleconsultation in orthopaedic surgery: A systematic review and meta-analysis of patient and physician experiences. J Telemed Telecare 2022; 28:471-480. [PMID: 32873138 DOI: 10.1177/1357633x20950995] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The primary purpose of this review was to evaluate patient and physician preference and satisfaction for teleconsultation in orthopaedic surgery compared to traditional face-to-face consultation. In addition, we evaluated the effects of teleconsultation on patient length of visit, healthcare costs, range of motion (ROM), pain, quality of life (QOL), and ongoing management plans. METHODS A systematic review of MEDLINE, Embase, Web of Science, and Cochrane Library was conducted according to PRISMA guidelines. Randomised control trials and case control studies comparing teleconsultation with traditional, face-to-face consultation in the management of orthopaedic conditions were included. The primary outcome measures were patient and physician preference and satisfaction. Secondary outcomes included patient length of visit, healthcare costs, ROM, pain, QOL, and ongoing management plans. RESULTS A total of 13 articles meeting the eligibility criteria were included for systematic review and 8 for meta-analysis. There was no significant difference in patient satisfaction, length of visit, or time spent with the physician between the telemedicine and in-office control group. The mean difference of patient preference for telemedicine was significantly higher in the telemedicine group compared to the in-office visit group (OR 1.44, 95% CI 1.12-1.87, p = 0.005). DISCUSSION Telemedicine was not inferior to face-to-face office visits in regard to patient and physician preference and satisfaction. Therefore, it would be an effective adjunct to face-to-face office visits, serving as a mechanism of triage and long-term continuity of care.
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Affiliation(s)
| | - David Kieser
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, Christchurch School of Medicine, New Zealand
| | - Christopher Frampton
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, Christchurch School of Medicine, New Zealand
| | - Michael C Wyatt
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, Christchurch School of Medicine, New Zealand
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Sharara A, Felcida V, Anwar S, Perera S, Lip PL. Patient perceptions on telemedicine eye clinics during COVID-19 pandemic. Int J Clin Pract 2021; 75:e14648. [PMID: 34670353 PMCID: PMC8646287 DOI: 10.1111/ijcp.14648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
| | | | - Saba Anwar
- Birmingham & Midland Eye CentreBirminghamUK
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Romero RJ, Martinez-Mier G, Ayala-García MA, Beristain-Hernández JL, Chan-Nuñez LC, Chapa-Azuela O, Dominguez-Rosado I, Flores-Villalba E, Fuentes-Orozco C, García-Covarrubias L, González-Ojeda A, Herrera-Hernández MF, Martinez-Ordaz JL, Medina-Franco H, Mercado MA, Montalvo-Jave E, Nuño-Guzmán CM, Torices-Escalante E, Torres-Villalobos GM, Vilatoba-Chapa M, Zamora-Godinez J, Zapata-Chavira H, Zerrweck-Lopez C. Establishing consensus on the perioperative management of cholecystectomy in public hospitals: a Delphi study with an expert panel in Mexico. HPB (Oxford) 2021; 23:685-699. [PMID: 33071151 DOI: 10.1016/j.hpb.2020.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/16/2020] [Accepted: 09/25/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Several guidelines have put forward recommendations about the perioperative process of cholecystectomy. Despite the recommendations, controversy remains concerning several topics, especially in low- and middle-income countries. The aim of this study was to develop uniform recommendations for perioperative practices in cholecystectomy in Mexico to standardize this process and save public health system resources. METHODS A modified Delphi method was used. An expert panel of 23 surgeons anonymously completed two rounds of responses to a 29-item questionnaire with 110 possible answers. The consensus was assessed using the percentage of responders agreeing on each question. RESULTS From the 29 questions, the study generated 27 recommendations based on 20 (69.0%) questions reaching consensus, one that was considered uncertain (3.4%), and six (20.7%) items that remained open questions. In two (6.9%) cases, no consensus was reached, and no recommendation could be made. CONCLUSIONS This study provides recommendations for the perioperative management of cholecystectomy in public hospitals in Mexico. As a guide for public institutions in low- and middle-income countries, the study identifies recommendations for perioperative tests and evaluations, perioperative decision making, postoperative interventions and institutional investment, that might ensure the safe practice of cholecystectomy and contribute to conserving resources.
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Affiliation(s)
- Rey Jesus Romero
- Department of Bariatric & Metabolic Surgery, Spanish Hospital of Veracruz, 16 de Septiembre 955 Col. Centro, 91700, Veracruz, Ver., Mexico.
| | - Gustavo Martinez-Mier
- Department of Hepato-Biliary Surgery & Transplantation, High Speciality Medical Unit 14, Mexican Institute of Social Security, Cuahutémoc Col. Formando Hogar, 91810, Veracruz, Ver., Mexico
| | - Marco A Ayala-García
- Department of Surgery & Research, General Hospital Zone 58, Mexican Institute of Social Security, Boulevard Jorge Vértiz Campero 1949 Col, San Miguel de Rentería, 37238, León, Gto., Mexico
| | - Jose Luis Beristain-Hernández
- Department of Hepato-Biliary Surgery, National Medical Center "Antonio Fraga Mouret, La Raza", Seris y Zaachila Col. La Raza, 02990, Mexico City, Mexico
| | - Luis Carlos Chan-Nuñez
- Department of Hepato-Biliary Surgery, National Institute of Medical Sciences and Nutrition "Salvador Zubirán", Vasco de Quiróga 15 Col. Belisario Dominguez, 14080, Mexico City, Mexico
| | - Oscar Chapa-Azuela
- Department of Hepato-Pancreato-Biliary Surgery, General Hospital of Mexico "Dr. Eduardo Liceaga", Dr. Balmis 148 Col. Doctores, 06720, Mexico City, Mexico
| | - Ismael Dominguez-Rosado
- Department of Hepato-Biliary Surgery, National Institute of Medical Sciences and Nutrition "Salvador Zubirán", Vasco de Quiróga 15 Col. Belisario Dominguez, 14080, Mexico City, Mexico
| | - Eduardo Flores-Villalba
- Department of Hepato-Biliary Surgery & Transplantation, Zambrano Hellion Medical Center Monterrey Institute of Technology and Higher Education, Batallón de San Patricio 112 Col. Real San Agustín, 66278, San Pedro Garza García, N.L., Mexico
| | - Clotilde Fuentes-Orozco
- Department of Surgery & Research, Western National Medical Center, Mexican Institute of Social Security, Belisario Dominguez 1000 Col. Belisario Dominguez, 44329, Guadalajara, Jal., Mexico
| | - Luis García-Covarrubias
- Department of Transplantation, General Hospital of Mexico "Dr. Eduardo Liceaga", Dr. Balmis 148 Col. Doctores, 06720, Mexico City, Mexico
| | - Alejandro González-Ojeda
- Department of Surgery & Research, Western National Medical Center, Mexican Institute of Social Security, Belisario Dominguez 1000 Col. Belisario Dominguez, 44329, Guadalajara, Jal., Mexico
| | - Miguel Francisco Herrera-Hernández
- Department of Endocrine Surgery, National Institute of Medical Sciences and Nutrition "Salvador Zubirán", Vasco de Quiróga 15 Col. Belisario Dominguez, 14080, Mexico City, Mexico
| | - José Luis Martinez-Ordaz
- Department of Surgery, XXI Century National Medical Center, Mexican Institute of Social Security, Av. Cuahutémoc 33 Col. Doctores, 06720, Mexico City, Mexico
| | - Heriberto Medina-Franco
- Department of Surgical Oncology, National Institute of Medical Sciences and Nutrition "Salvador Zubirán", Vasco de Quiróga 15 Col. Belisario Dominguez, 14080, Mexico City, Mexico
| | - Miguel Angel Mercado
- Department of Surgery, National Institute of Medical Sciences and Nutrition "Salvador Zubirán", Vasco de Quiróga 15 Col. Belisario Dominguez, 14080, Mexico City, Mexico
| | - Eduardo Montalvo-Jave
- Department of Hepato-Pancreato-Biliary Surgery, General Hospital of Mexico "Dr. Eduardo Liceaga", Dr. Balmis 148 Col. Doctores, 06720, Mexico City, Mexico
| | - Carlos Martine Nuño-Guzmán
- Department of Surgery, Civil Hospital "Fray Antonio Alcalde", Hospital 278 Col. El Retiro, 44280, Guadalajara, Jal., Mexico
| | - Eduardo Torices-Escalante
- Department of Gastrointestinal Endoscopy, Regional Hospital October 1st, Institute for Social Security and Services for State Workers, Av. Politécnico Nacional 1669 Col. Magdalena de las Salinas, 07300, Mexico City, Mexico
| | - Gonzalo Manuel Torres-Villalobos
- Department of Experimental Surgery & Minimally Invasive Surgery, National Institute of Medical Sciences and Nutrition "Salvador Zubirán", Vasco de Quiróga 15 Col. Belisario Dominguez, 14080, Mexico City, Mexico
| | - Mario Vilatoba-Chapa
- Department of Transplantation, National Institute of Medical Sciences and Nutrition "Salvador Zubirán", Vasco de Quiróga 15 Col. Belisario Dominguez, 14080, Mexico City, Mexico
| | - Jordán Zamora-Godinez
- Department of Surgery, General Hospital Zone 8, Mexican Institute of Social Security, Calle 18 de julio 214 Col. Periodistas, 42060, Pachuca, Hgo., Mexico
| | - Homero Zapata-Chavira
- Department of Surgery & Transplantation, University Hospital "Dr. José E. González", Av. Gonzalitos 235 Col. Mitras Centro, 64460, Monterrey, N.L., Mexico
| | - Carlos Zerrweck-Lopez
- Department of Bariatric & Metabolic Surgery, Tláhuac General Hospital, Av. La Turba 655 Col. Villa Centroamericana, 13250, Mexico City, Mexico
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Baughman BD, Hansemann BK, Shah MM, Weizer JS. Drive-through Intraocular Pressure Checks During the COVID-19 Pandemic. J Glaucoma 2021; 30:223-226. [PMID: 33273284 DOI: 10.1097/ijg.0000000000001748] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 11/14/2020] [Indexed: 11/26/2022]
Abstract
PRECIS A drive-through clinic was created to obtain intraocular pressure measurements before a virtual visit with their provider, in order to provide care for patients in the Kellogg Glaucoma Clinic while minimizing risk of COVID-19 transmission. PURPOSE The aim of this study was to establish a drive-through clinic model to provide glaucoma care for patients while minimizing the risk of COVID-19 transmission. PATIENTS AND METHODS A drive-through clinic was created by adapting a 1-lane, 1-way driveway adjacent to the Kellogg Eye Center building entrance. Patients were physicianselected from the Glaucoma Clinic at Kellogg Eye Center as existing patients who required intraocular pressure (IOP) checks and therapeutic management and were chosen based on their ability to be managed with an IOP measurement primarily. The entrance was otherwise closed to the public, allowing staff to utilize an adjacent vestibule with glass walls and sliding doors as a staffroom. Patients were instructed to arrive within a 15-minute time window at which time they would drive through the lane and stop their cars under an awning over the driveway. Ophthalmic technicians wearing appropriate personal protective equipment then approached each car, confirmed patient information, and measured IOP. Once the data were recorded using a mobile workstation, the physician was able to complete each visit by discussing the findings and therapeutic plan with the patient, either in-person in real time or virtually by phone or video visit at a later time. RESULTS A total of 241 visits were completed over 14 half day clinic sessions, with number of drive-through visits ranging from 5 to 45 per session. CONCLUSIONS It is possible to institute a drive-through model of IOP checks for glaucoma patients which is efficient and minimizes the risk of exposure to COVID-19 for patients and staff.
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Affiliation(s)
| | | | - Manjool M Shah
- Kellogg Eye Center, University of Michigan, Ann Arbor, MI
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Lamplot JD, Taylor SA. Good Comes From Evil: COVID-19 and the Advent of Telemedicine in Orthopedics. HSS J 2021; 17:7-13. [PMID: 33967635 PMCID: PMC8077989 DOI: 10.1177/1556331620972046] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 01/14/2023]
Affiliation(s)
- Joseph D. Lamplot
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | - Samuel A. Taylor
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA
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Rhind JH, Ramhamadany E, Collins R, Govilkar S, Dass D, Hay S. An analysis of virtual fracture clinics in orthopaedic trauma in the UK during the coronavirus crisis. EFORT Open Rev 2020; 5:442-448. [PMID: 32818071 PMCID: PMC7407867 DOI: 10.1302/2058-5241.5.200041] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Virtual fracture clinics (VFC) are advocated by new orthopaedic (British Orthopaedic Association) and National Health Service (NHS) guidelines in the United Kingdom. We discuss benefits and limitations, reviewing the literature, as well as recommendations on introducing a VFC service during the coronavirus pandemic and into the future.A narrative review identifying current literature on virtual fracture clinic outcomes when compared to traditional model fracture clinics in the UK. We identify nine relevant publications related to VFC.The Glasgow model, initiated in 2011, has become the benchmark. Clinical efficiency can be improved, reducing the number of emergency department (ED) referrals seen in VFC by 15-28% and face-to-face consultations by 65%. After review in the VFC, 33-60% of patients may be discharged. Some studies have shown no negative impact on the ED; the time to discharge was not increased. Patient satisfaction ranges from 91-97% using a VFC service, and there may be cost-saving benefits annually of £67,385 to £212,705. Non-attendance may be reduced by 75% and there are educational opportunities for trainees. However, evidence is limited; 28% of patients prefer face-to-face consultations and not all have access to internet or email (72%).We propose a pathway integrating the VFC model, whilst having senior orthopaedic decision makers available in the ED, during normal working hours, to cope with the pandemic. Beyond the pandemic, evidence suggests the Glasgow model is viable for day-to-day practice. Cite this article: EFORT Open Rev 2020;5:442-448. DOI: 10.1302/2058-5241.5.200041.
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Affiliation(s)
| | | | - Ruaraidh Collins
- Basingstoke and North Hampshire Hospital, Basingstoke, Hampshire, UK
| | | | - Debashis Dass
- Robert Jones Agnes Hunt Hospital, Oswestry, Shropshire, UK
| | - Stuart Hay
- Robert Jones Agnes Hunt Hospital, Oswestry, Shropshire, UK
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Cottrell E, George A, Coulson C, Chambers R. Telescopic otology referrals: Evaluation of feasibility and acceptability. Laryngoscope Investig Otolaryngol 2020; 5:221-227. [PMID: 32337353 PMCID: PMC7178442 DOI: 10.1002/lio2.367] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/22/2020] [Accepted: 02/08/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE A remote telemedical otology referral and advice service was introduced to interested general practices. General practitioners (GPs) were given a new device, "endoscope-i" that combines an optimized smartphone high definition video app with an otoendoscope. They were specifically trained to examine and capture images of patients' eardrums, which were sent electronically with a summary of clinical information and an in-app hearing testing (if required), for specialist advice to two ear, nose, and throat (ENT) consultants. We describe the findings from an evaluation of the first 6 months of this service to establish the feasibility and acceptability of an otology telemedical referral and advice service. METHODS The new service was advertised to GP practices in Northern Staffordshire. All interested GPs were provided with training and equipment to deliver the remote referral service. Data were collected from GPs at baseline, informal feedback in response to referral outcomes and end of service feedback. Referral data were collected routinely during the service delivery. RESULTS Fifteen GP leads from 15 practices received training and equipment. One quickly lost the equipment. Of the remaining 14 practices, eight sent a total of 53 remote referrals using this technology over 6 months. The most common reason for referral was an uncertainty of what could be seen in or around the eardrum. The primary barrier for implementation was lack of wireless internet connections within practices. GPs reported that they used this technology to share examination findings with patients. CONCLUSIONS GPs were positive about the technology, from initial engagement with training and after advice were given. Some GPs expanded the role of the technology to a consultation aid. Referral volume was manageable. Commissioners should consider tariffs structures for such services; empirical cost-effectiveness and workload-impact evaluation would inform this.
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Affiliation(s)
| | - Ajith George
- Department of ENT University Hospital of North Midlands UK
| | - Chris Coulson
- Department of ENT Queen Elizabeth Hospital Birmingham UK
| | - Ruth Chambers
- Staffordshire Sustainability & Transformation Partnership Clinical Lead for Technology Enabled Care Services, Digital Workstream UK
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Rutherford E, Noray R, Ó hEarráin C, Quinlan K, Hegarty A, Ekpotu L, Arize C, Fabamwo F, Alrubaiaan A, Bhupalan A, Alshehhi A, Power C, Hill ADK. Potential Benefits and Drawbacks of Virtual Clinics in General Surgery: Pilot Cross-Sectional Questionnaire Study. JMIR Perioper Med 2020; 3:e12491. [PMID: 33932277 PMCID: PMC7728406 DOI: 10.2196/12491] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 06/05/2019] [Accepted: 10/29/2019] [Indexed: 11/29/2022] Open
Abstract
Background Escalating demand for specialist health care puts considerable demand on hospital services. Technology offers a means by which health care providers may increase the efficiency of health care delivery. Objective The aim of this study was to conduct a pilot study of the feasibility, benefits, and drawbacks of a virtual clinic (VC) in the general surgical service of a busy tertiary center. Methods Patient satisfaction with current care and attitudes to VC were surveyed prospectively in the general surgical outpatient department (OPD; n=223). A subset of patients who had undergone endoscopy and day surgery were recruited to follow-up in a VC and subsequently surveyed with regard to their satisfaction (20/243). Other outcomes measured included a comparison of consultation times in traditional and virtual outpatient settings and financial cost to both patients and the institution. Results Almost half of the patients reported barriers to prospective use of VCs. However, within the cohort who had been followed-up in the VC, satisfaction was higher than the traditional OPD (100% as compared with 187/223, 83.9%). Significant savings in both time (P=.003) and financial costs to patients and the institution were found. Conclusions For an appropriately selected group of patients, VCs offer a viable alternative to traditional OPD. This alternative can improve both patient satisfaction and efficiency of patient care.
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Affiliation(s)
- Emily Rutherford
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Roghinio Noray
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Caolán Ó hEarráin
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Kevin Quinlan
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Aisling Hegarty
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Lenin Ekpotu
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Chinedum Arize
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fiyinfoluwa Fabamwo
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Avinash Bhupalan
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Abdulla Alshehhi
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Colm Power
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
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12
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Mold F, Hendy J, Lai YL, de Lusignan S. Electronic Consultation in Primary Care Between Providers and Patients: Systematic Review. JMIR Med Inform 2019; 7:e13042. [PMID: 31793888 PMCID: PMC6918214 DOI: 10.2196/13042] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 06/11/2019] [Accepted: 08/07/2019] [Indexed: 12/27/2022] Open
Abstract
Background Governments and health care providers are keen to find innovative ways to deliver care more efficiently. Interest in electronic consultation (e-consultation) has grown, but the evidence of benefit is uncertain. Objective This study aimed to assess the evidence of delivering e-consultation using secure email and messaging or video links in primary care. Methods A systematic review was conducted on the use and application of e-consultations in primary care. We searched 7 international databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, PsycINFO, EconLit, and Web of Science; 1999-2017), identifying 52 relevant studies. Papers were screened against a detailed inclusion and exclusion criteria. Independent dual data extraction was conducted and assessed for quality. The resulting evidence was synthesized using thematic analysis. Results This review included 57 studies from a range of countries, mainly the United States (n=30) and the United Kingdom (n=13). There were disparities in uptake and utilization toward more use by younger, employed adults. Patient responses to e-consultation were mixed. Patients reported satisfaction with services and improved self-care, communication, and engagement with clinicians. Evidence for the acceptability and ease of use was strong, especially for those with long-term conditions and patients located in remote regions. However, patients were concerned about the privacy and security of their data. For primary health care staff, e-consultation delivers challenges around time management, having the correct technological infrastructure, whether it offers a comparable standard of clinical quality, and whether it improves health outcomes. Conclusions E-consultations may improve aspects of care delivery, but the small scale of many of the studies and low adoption rates leave unanswered questions about usage, quality, cost, and sustainability. We need to improve e-consultation implementation, demonstrate how e-consultations will not increase disparities in access, provide better reassurance to patients about privacy, and incorporate e-consultation as part of a manageable clinical workflow.
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Affiliation(s)
- Freda Mold
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Jane Hendy
- Brunel Business School, Brunel University London, Uxbridge, United Kingdom
| | - Yi-Ling Lai
- Faculty of Business and Law, University of Portsmouth, Portsmouth, United Kingdom
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, United Kingdom
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13
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Siegel A, Ehmann AT, Meyer I, Gröne O, Niebling W, Martus P, Rieger MA. PEN-13: A New Generic 13-Item Questionnaire for Measuring Patient Enablement (German Version). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E4867. [PMID: 31816911 PMCID: PMC6926737 DOI: 10.3390/ijerph16234867] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 11/28/2019] [Indexed: 11/16/2022]
Abstract
Background: The purpose of our study was to develop and psychometrically test a German-language survey instrument that measures patient enablement generically and in greater detail than previous instruments. Methods: A multidisciplinary team developed 13 items to capture individual aspects of patient enablement (PEN-13). A pre-test with 26 subjects was followed by a random sample survey of N = 1168 subjects. An exploratory factor analysis was conducted in a random split-half sample of the data to explore PEN-13's factor structure; a confirmatory factor analysis was conducted in the validation sample. The internal consistency of the factors was evaluated using Cronbach's alpha, PEN-13's construct validity was checked by means of additional hypothesis testing. Results: The two factors self-management and patient-practitioner interaction, detected in the exploratory analysis, were confirmed with a few modifications in the confirmatory factor analysis, with the comparative fit index (CFI) amounting to 0.903. The Cronbach's alpha values of those two factors amounted to α = 0.90 and α = 0.82, respectively. The correlations of the PEN-13 score with the 'general self-efficacy' and 'health literacy' (HLS-EU-Q16) scores further confirmed its construct validity; the respective correlation coefficients amounted to 0.57 and 0.60. Conclusion: The German version of the survey instrument Patient Enablement Scale-13 items (PEN-13) shows acceptable psychometric properties. Practical implications: PEN-13 seems particularly suitable for health services research purposes. We recommend checking the results in another sample as well as evaluating its responsiveness to enablement-enhancing interventions.
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Affiliation(s)
- Achim Siegel
- Institute of Occupational and Social Medicine and Health Services Research, University Hospital Tübingen, Wilhelmstraße 27, 72074 Tübingen, Germany; (A.T.E.); (M.A.R.)
| | - Anna T. Ehmann
- Institute of Occupational and Social Medicine and Health Services Research, University Hospital Tübingen, Wilhelmstraße 27, 72074 Tübingen, Germany; (A.T.E.); (M.A.R.)
| | - Ingo Meyer
- PMV forschungsgruppe, University of Cologne, Herderstraße 52, 50391 Cologne, Germany;
| | - Oliver Gröne
- OptiMedis AG, Burchardstraße 17, 20095 Hamburg, Germany;
- London School of Hygiene and Tropical Medicine, University of London, London WC1E 7HT, UK
| | - Wilhelm Niebling
- Division of General Practice, University Medical Center Freiburg, 79910 Freiburg, Germany;
| | - Peter Martus
- Institute for Clinical Epidemiology and Applied Biometry, University Hospital Tübingen, Silcherstr. 5, 72076 Tübingen, Germany;
| | - Monika A. Rieger
- Institute of Occupational and Social Medicine and Health Services Research, University Hospital Tübingen, Wilhelmstraße 27, 72074 Tübingen, Germany; (A.T.E.); (M.A.R.)
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14
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Chuo J, Webster KA. Practical use of telemedicine in the chronically ventilated infant. Semin Fetal Neonatal Med 2019; 24:101036. [PMID: 31727571 DOI: 10.1016/j.siny.2019.101036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Telemedicine, or the use of electronic communication technology to improve patient health, is becoming more widely adopted as a means of bringing together patients, providers and family members to facilitate evaluation, monitoring, diagnosis and treatment. A particularly vulnerable group consists of children with dependence on technology, such as chronic mechanical ventilation. This chapter will provide an overview of how telehealth technology is currently being used, for supporting this patient population through 1) inpatient support 2) integration with the medical home 3) bridging care transitions 4) remote patient management and 5) multispecialty consultations. We will also discuss the impact on quality and cost, the current research environment and practical points for implementation into clinical practice.
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Affiliation(s)
- John Chuo
- Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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15
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Buvik A, Bergmo TS, Bugge E, Smaabrekke A, Wilsgaard T, Olsen JA. Cost-Effectiveness of Telemedicine in Remote Orthopedic Consultations: Randomized Controlled Trial. J Med Internet Res 2019; 21:e11330. [PMID: 30777845 PMCID: PMC6399572 DOI: 10.2196/11330] [Citation(s) in RCA: 196] [Impact Index Per Article: 39.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 11/22/2018] [Accepted: 12/09/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Telemedicine consultations using real-time videoconferencing has the potential to improve access and quality of care, avoid patient travels, and reduce health care costs. OBJECTIVE The aim of this study was to examine the cost-effectiveness of an orthopedic videoconferencing service between the University Hospital of North Norway and a regional medical center in a remote community located 148 km away. METHODS An economic evaluation based on a randomized controlled trial of 389 patients (559 consultations) referred to the hospital for an orthopedic outpatient consultation was conducted. The intervention group (199 patients) was randomized to receive video-assisted remote orthopedic consultations (302 consultations), while the control group (190 patients) received standard care in outpatient consultation at the hospital (257 consultations). A societal perspective was adopted for calculating costs. Health outcomes were measured as quality-adjusted life years (QALYs) gained. Resource use and health outcomes were collected alongside the trial at baseline and at 12 months follow-up using questionnaires, patient charts, and consultation records. These were valued using externally collected data on unit costs and QALY weights. An extended sensitivity analysis was conducted to address the robustness of the results. RESULTS This study showed that using videoconferencing for orthopedic consultations in the remote clinic costs less than standard outpatient consultations at the specialist hospital, as long as the total number of patient consultations exceeds 151 per year. For a total workload of 300 consultations per year, the annual cost savings amounted to €18,616. If costs were calculated from a health sector perspective, rather than a societal perspective, the number of consultations needed to break even was 183. CONCLUSIONS This study showed that providing video-assisted orthopedic consultations to a remote clinic in Northern Norway, rather than having patients travel to the specialist hospital for consultations, is cost-effective from both a societal and health sector perspective. This conclusion holds as long as the activity exceeds 151 and 183 patient consultations per year, respectively. TRIAL REGISTRATION ClinicalTrials.gov NCT00616837; https://clinicaltrials.gov/ct2/show/NCT00616837 (Archived by WebCite at http://www.webcitation.org/762dZPoKX).
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Affiliation(s)
- Astrid Buvik
- Department of Orthopaedic Surgery, University Hospital of North Norway, Tromsø, Norway
| | - Trine S Bergmo
- Norwegian Centre for E-health Research, University Hospital of North Norway, Tromsø, Norway
| | - Einar Bugge
- Centre for Quality Improvement and Development, University Hospital of North Norway, Tromsø, Norway
| | - Arvid Smaabrekke
- Department of Orthopaedic Surgery, University Hospital of North Norway, Tromsø, Norway
| | - Tom Wilsgaard
- Centre for Quality Improvement and Development, University Hospital of North Norway, Tromsø, Norway.,Department of Community Medicine, The University of Tromsø - The Arctic University of Norway, Tromsø, Norway
| | - Jan Abel Olsen
- Department of Community Medicine, The University of Tromsø - The Arctic University of Norway, Tromsø, Norway.,Centre for Health Economics, Monash University, Melbourne, Victoria, Australia
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16
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O'Connell Francischetto E, Damery S, Ferguson J, Combes G. Video clinics versus standard face-to-face appointments for liver transplant patients in routine hospital outpatient care: study protocol for a pragmatic randomised evaluation of myVideoClinic. Trials 2018; 19:574. [PMID: 30340637 PMCID: PMC6195722 DOI: 10.1186/s13063-018-2953-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 09/29/2018] [Indexed: 12/20/2022] Open
Abstract
Background Video clinics, where patients can have a hospital appointment with their clinician from home, are emerging in practice, but their effectiveness is unclear. This study will evaluate whether a video clinic implemented at the University Hospitals Birmingham (UHB) NHS Foundation Trust improves patient satisfaction compared to standard face-to-face appointments for liver transplant patients. Methods This will be a parallel, two-arm, statistician-blinded, randomised evaluation. Clinically stable liver patients at 1 to 5 years post-transplant (n = 180) will be randomised in equal numbers to video clinic appointments (intervention) or standard face-to-face appointments (control). The intervention group will have outpatient appointments from home via a secure video link accessed through the UHB patient portal. All patients will complete baseline questionnaires before randomisation and electronic follow-up questionnaires after each follow-up appointment during the subsequent 12 months. The primary outcome is the difference in scores between groups for three domains of patient satisfaction, namely ‘convenience of location’, ‘getting through to the office by phone’ and ‘length of time waiting’ (modified Visit-Specific Satisfaction Instrument). Secondary outcomes include quality of life (EQ-5D-5 L), costs, clinical contacts and user experience. Statistical analysis will be descriptive and performed on an intention-to-treat basis. The primary outcome will be analysed using baseline and 3-, 6-, 9- and 12-month questionnaires (according to patient follow-up appointment frequency) and comparisons made between study arms. A within-trial cost consequences analysis will be undertaken on the economic data. Patients (n = 8), carers/family members (n = 6) and health professionals (n = 14) will be interviewed about the experience of video clinics and the interviews will be analysed using thematic analysis. Discussion This study will allow an in depth understanding of whether video clinics can improve patient satisfaction with their care. In addition, the intervention could save patients time and costs, removing the need to travel long distances for outpatient appointments. Video clinics may be applicable to a wide range of other clinical settings and health conditions. The study has been approved by the NHS Health Research Authority and a National Research Ethics Committee (Ref: 17/WM/0338) and research governance approval has been obtained from UHB (Ref: RRK6080). Trial registration ISRCTN: 14093266 (25/03/2018; retrospectively registered). Electronic supplementary material The online version of this article (10.1186/s13063-018-2953-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elaine O'Connell Francischetto
- Institute of Applied Health Research, Murray Learning Centre, University of Birmingham, Edgbaston, West Midlands, B15 2TT, UK.
| | - Sarah Damery
- Institute of Applied Health Research, Murray Learning Centre, University of Birmingham, Edgbaston, West Midlands, B15 2TT, UK
| | - James Ferguson
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, West Midlands, B15 2GW, UK.,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Mindelsohn Way, Edgbaston, West Midlands, B15 2GW, UK
| | - Gill Combes
- Institute of Applied Health Research, Murray Learning Centre, University of Birmingham, Edgbaston, West Midlands, B15 2TT, UK
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17
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Gallagher J, James S, Keane C, Fitzgerald A, Travers B, Quigley E, Hecht C, Zhou S, Watson C, Ledwidge M, McDonald K. Heart Failure Virtual Consultation: bridging the gap of heart failure care in the community - A mixed-methods evaluation. ESC Heart Fail 2017; 4:252-258. [PMID: 28772044 PMCID: PMC5542774 DOI: 10.1002/ehf2.12163] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 03/04/2017] [Accepted: 03/09/2017] [Indexed: 12/11/2022] Open
Abstract
Aims We undertook a mixed‐methods evaluation of a Web‐based conferencing service (virtual consult) between general practitioners (GPs) and cardiologists in managing patients with heart failure in the community to determine its effect on use of specialist heart failure services and acceptability to GPs. Methods and results All cases from June 2015 to October 2016 were recorded using a standardized recording template, which recorded patient demographics, medical history, medications, and outcome of the virtual consult for each case. Quantitative surveys and qualitative interviewing of 17 participating GPs were also undertaken. During this time, 142 cases were discussed—68 relating to a new diagnosis of heart failure, 53 relating to emerging deterioration in a known heart failure patient, and 21 relating to therapeutic issues. Only 17% required review in outpatient department following the virtual consultation. GPs reported increased confidence in heart failure management, a broadening of their knowledge base, and a perception of overall better patient outcomes. Conclusions These data from an initial experience with Heart Failure Virtual Consultation present a very positive impact of this strategy on the provision of heart failure care in the community and acceptability to users. Further research on the implementation and expansion of this strategy is warranted.
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Affiliation(s)
- Joseph Gallagher
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - Stephanie James
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,St Vincent's University Hospital Group, Dublin, Ireland
| | - Ciara Keane
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - Annie Fitzgerald
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,St Vincent's University Hospital Group, Dublin, Ireland
| | - Bronagh Travers
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,St Vincent's University Hospital Group, Dublin, Ireland
| | - Etain Quigley
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,Applied Research for Connected Health, NexusUCD, Dublin, Ireland
| | - Christina Hecht
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,Applied Research for Connected Health, NexusUCD, Dublin, Ireland
| | - Shuaiwei Zhou
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,Heartbeat Trust, Dun Laoghaire, Dublin, Ireland
| | - Chris Watson
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,Queen's University, Belfast, UK
| | - Mark Ledwidge
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland.,Heartbeat Trust, Dun Laoghaire, Dublin, Ireland
| | - Kenneth McDonald
- Heart Failure Unit, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland.,St Vincent's University Hospital Group, Dublin, Ireland.,Heartbeat Trust, Dun Laoghaire, Dublin, Ireland
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18
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Novoa NM, Gómez MT, Rodríguez M, Jiménez López MF, Aranda JL, Bollo de Miguel E, Diez F, Hernández Hernández J, Varela G. e-Consultation Improves Efficacy in Thoracic Surgery Outpatient Clinics. Arch Bronconeumol 2016; 52:549-552. [PMID: 27208914 DOI: 10.1016/j.arbres.2016.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 03/20/2016] [Accepted: 04/03/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The aim of this study is analysing the impact of the systematic versus occasional videoconferencing discussion of patients with two respiratory referral units along 6 years of time over the efficiency of the in-person outpatient clinics of a thoracic surgery service. METHOD Retrospective and comparative study of the evaluated patients through videoconferencing and in-person first visits during two equivalents periods of time: Group A (occasional discussion of cases) between 2008-2010 and Group B (weekly regular discussion) 2011-2013. Data were obtained from two prospective and electronic data bases. The number of cases discussed using e-consultation, in-person outpatient clinics evaluation and finally operated on under general anaesthesia in each period of time are presented. For efficiency criteria, the index: number of operated on cases/number of first visit outpatient clinic patients is created. Non-parametric Wilcoxon test is used for comparison. RESULTS The mean number of patients evaluated at the outpatient clinics/year on group A was 563 versus 464 on group B. The median number of cases discussed using videoconferencing/year was 42 for group A versus 136 for group B. The mean number of operated cases/first visit at the outpatient clinics was 0.7 versus 0.87 in group B (P=.04). CONCLUSIONS The systematic regular discussion of cases using videoconferencing has a positive impact on the efficacy of the outpatient clinics of a Thoracic Surgery Service measured in terms of operated cases/first outpatient clinics visit.
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Affiliation(s)
- Nuria M Novoa
- Servicio de Cirugía Torácica, Hospital Universitario de Salamanca, Salamanca, España.
| | - Maria Teresa Gómez
- Servicio de Cirugía Torácica, Hospital Universitario de Salamanca, Salamanca, España
| | - María Rodríguez
- Servicio de Cirugía Torácica, Hospital Universitario de Salamanca, Salamanca, España
| | | | - Jose L Aranda
- Servicio de Cirugía Torácica, Hospital Universitario de Salamanca, Salamanca, España
| | | | - Florentino Diez
- Servicio de Neumología, Complejo Asistencial Universitario de León, León, España
| | | | - Gonzalo Varela
- Servicio de Cirugía Torácica, Hospital Universitario de Salamanca, Salamanca, España
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19
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Winpenny E, Miani C, Pitchforth E, Ball S, Nolte E, King S, Greenhalgh J, Roland M. Outpatient services and primary care: scoping review, substudies and international comparisons. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04150] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
AimThis study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B.Outpatient Services and Primary Care: A Scoping Review of Research Into Strategies For Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services.Findings from the scoping reviewEvidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for these approaches there is very limited information on cost-effectiveness; we do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches. One promising development is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals.Findings from the substudiesBecause of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches included the use of financial mechanisms and incentives, the transfer of work to primary care, the relocation of specialists and the use of guidelines and protocols. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS.ConclusionsFor many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.FundingThe NIHR Health Services and Delivery Research programme.
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Affiliation(s)
| | | | | | | | - Ellen Nolte
- RAND Europe, Cambridge, UK
- European Observatory on Health Systems and Policies, London School of Economics and Political Science and London School of Hygiene and Tropical Medicine, London, UK
| | | | - Joanne Greenhalgh
- Faculty of Education, Social Sciences and Law, University of Leeds, Leeds, UK
| | - Martin Roland
- Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UK
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20
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Affiliation(s)
- Nathaniel P Brooks
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA.
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21
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Tejera Segura B, Bustabad S. Una nueva forma de comunicación entre reumatología y atención primaria: la consulta virtual. ACTA ACUST UNITED AC 2016; 12:11-4. [DOI: 10.1016/j.reuma.2015.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 11/14/2014] [Accepted: 01/08/2015] [Indexed: 10/24/2022]
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22
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Flodgren G, Rachas A, Farmer AJ, Inzitari M, Shepperd S. Interactive telemedicine: effects on professional practice and health care outcomes. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [PMID: 26343551 DOI: 10.1002/14651858.cd002098.pub2.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Gerd Flodgren
- Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Roosevelt Drive, Headington, Oxford, Oxfordshire, UK, OX3 7LF
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Flodgren G, Rachas A, Farmer AJ, Inzitari M, Shepperd S. Interactive telemedicine: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2015; 2015:CD002098. [PMID: 26343551 PMCID: PMC6473731 DOI: 10.1002/14651858.cd002098.pub2] [Citation(s) in RCA: 329] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Gerd Flodgren
- Norwegian Institute of Public HealthThe Norwegian Knowledge Centre for the Health ServicesPilestredet Park 7OsloNorway0176
| | - Antoine Rachas
- European Hospital Georges Pompidou and Paris Descartes UniversityDepartment of IT and Public Health20‐40 Rue leBlancParisFrance75908
| | - Andrew J Farmer
- University of OxfordNuffield Department of Primary Care Health SciencesRadcliffe Observatory Quarter, Walton StreetOxfordUKOX2 6GG
| | - Marco Inzitari
- Parc Sanitari Pere Virgili and Universitat Autònoma de BarcelonaDepartment of Healthcare/Medicinec Esteve Terrades 30BarcelonaSpain08023
| | - Sasha Shepperd
- University of OxfordNuffield Department of Population HealthRosemary Rue Building, Old Road CampusHeadingtonOxfordOxfordshireUKOX3 7LF
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Blank L, Baxter S, Woods HB, Goyder E, Lee A, Payne N, Rimmer M. What is the evidence on interventions to manage referral from primary to specialist non-emergency care? A systematic review and logic model synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03240] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BackgroundDemand management describes any method used to monitor, direct or regulate patient referrals. Several strategies have been developed to manage the referral of patients to secondary care, with interventions targeting primary care, specialist services, or infrastructure.ObjectiveThis research aimed to conduct an inclusive systematic review and logic model synthesis in order to better understand factors impacting on the effectiveness of interventions targeting referral between primary and secondary medical health care.DesignThe approach combined systematic review with logic modelling synthesis techniques to develop an evidence-based framework of factors influencing the pathway between interventions and system-wide changes.SettingPrimary health care.Main outcome measuresReferral from primary to secondary care.Review methodsSystematic searches were undertaken to identify recent, relevant studies. Quality of individual studies was appraised, with consideration of overall strength of evidence. A narrative synthesis and logic model summary of the data was completed.ResultsFrom a database of 8327 unique papers, 290 were included in the review. The intervention studies were grouped into four categories of education interventions (n = 50); process change interventions (n = 49); system change interventions (n = 38); and patient-focused interventions (n = 3). Effectiveness was assessed variously in these papers; however, there was a gap regarding the mechanisms whereby these interventions lead to demand management impacts. The findings suggest that, although individual-level interventions may be popular, the stronger evidence relates only to peer-review and feedback interventions. Process change interventions appeared to be more effective when the change resulted in the specialist being provided with more or better quality information about the patient. System changes including the community provision of specialist services by general practitioners, outreach provision by specialists and the return of inappropriate referrals appeared to have evidence of effect. The pathway whereby interventions might lead to service-wide impact was complex, with multiple factors potentially acting as barriers or facilitators to the change process. Factors related, first, to the doctor (including knowledge, attitudes and beliefs, and previous experiences of a service), second, to the patient (including condition and social factors) and, third, to the influence of the doctor–patient relationship. We also identified a number of potentially influential factors at a local level, such as perceived waiting times and the availability of a specialist. These elements are key factors in the pathway between an intervention and intended demand management outcomes influencing both applicability and effectiveness.ConclusionsThe findings highlight the complexity of the referral process and multiple elements that will impact on intervention outcomes and applicability to a local area. Any interventions seeking to change referral practice need to address factors relating to the individual practitioner, the patient and also the situation in which the referral is taking place. These conclusions apply especially to referral management in a UK context where this whole range of factors/issues lies well within the remit of the NHS. This work highlights that intermediate outcomes are important in the referral pathway. It is recommended that researchers include measure of these intermediate outcomes in their evaluation of intervention effectiveness in order to determine where blocks to or facilitators of system-wide impact may be occurring.Study registrationThe study is registered as PROSPERO CRD42013004037.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Lindsay Blank
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Susan Baxter
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Helen Buckley Woods
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Lee
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Nick Payne
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Melanie Rimmer
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Patient Empowerment and its neighbours: Clarifying the boundaries and their mutual relationships. Health Policy 2015; 119:384-94. [DOI: 10.1016/j.healthpol.2014.10.017] [Citation(s) in RCA: 147] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 10/22/2014] [Accepted: 10/27/2014] [Indexed: 11/18/2022]
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Blank L, Baxter S, Woods HB, Goyder E, Lee A, Payne N, Rimmer M. Referral interventions from primary to specialist care: a systematic review of international evidence. Br J Gen Pract 2014; 64:e765-74. [PMID: 25452541 PMCID: PMC4240149 DOI: 10.3399/bjgp14x682837] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 06/11/2014] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Demand management defines any method used to monitor, direct, or regulate patient referrals. Strategies have been developed to manage the referral of patients to secondary care, with interventions that target primary care, specialist services, or infrastructure. AIM To review the international evidence on interventions to manage referral from primary to specialist care. DESIGN AND SETTING Systematic review. METHOD Iterative, systematic searches of published and unpublished sources public health, health management, management, and grey literature databases from health care and other industries were undertaken to identify recent, relevant studies. A narrative synthesis of the data was completed to structure the evidence into groups of similar interventions. RESULTS The searches generated 8327 unique results, of which 140 studies were included. Interventions were grouped into four intervention categories: GP education (n = 50); process change (n = 49); system change (n = 38); and patient-focused (n = 3). It is clear that there is no 'magic bullet' to managing demand for secondary care services: although some groups of interventions may have greater potential for development, given the existing evidence that they can be effective in specific contexts. CONCLUSIONS To tackle demand management of primary care services, the focus cannot be on primary care alone; a whole-systems approach is needed because the introduction of interventions in primary care is often just the starting point of the referral process. In addition, more research is needed to develop and evaluate interventions that acknowledge the role of the patient in the referral decision.
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Affiliation(s)
- Lindsay Blank
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Susan Baxter
- School of Health and Related Research, University of Sheffield, Sheffield
| | | | - Elizabeth Goyder
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Andrew Lee
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Nick Payne
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Melanie Rimmer
- School of Health and Related Research, University of Sheffield, Sheffield
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Raven M, Butler C, Bywood P. Video-based telehealth in Australian primary health care: current use and future potential. Aust J Prim Health 2014; 19:283-6. [PMID: 24134865 DOI: 10.1071/py13032] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 09/03/2013] [Indexed: 11/23/2022]
Abstract
Many Australians have limited access to health-care services due to a range of barriers, including geographic distance and restricted mobility, which telehealth can potentially address. This paper reviews the current and potential use of video consultation in primary health care in Australia, drawing on international literature. There is substantial evidence of high patient satisfaction, but many studies have methodological limitations. Overall, evidence of effectiveness and cost-effectiveness is weak. There is reasonable evidence for diagnosis, home care and specialist consultations by GPs with patients present. Two telehealth initiatives using video consultation are briefly presented. Both provide evidence that video consultation has a valuable role to play, but does not obviate the need for face-to-face consultations. Video consultation challenges traditional professional roles, particularly those of nurses, and can improve health workers' skills and job satisfaction. More fundamentally, telehealth challenges the traditional distinction between primary and secondary care. This can be a source of resistance but may ultimately be one of its strengths. Appropriately targeted video consultation has much potential to improve the delivery of primary health care in Australia, particularly in rural and remote regions.
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Affiliation(s)
- Melissa Raven
- Primary Health Care Research and Information Service, Discipline of General Practice, Level 3, Health Sciences Building, Registry Road, Flinders University, GPO Box 2100, Adelaide, SA 5001, Australia
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Ryan EM, Rogers AC, Hanly AM, McCawley N, Deasy J, McNamara DA. A virtual outpatient department provides a satisfactory patient experience following endoscopy. Int J Colorectal Dis 2014; 29:359-64. [PMID: 24309978 DOI: 10.1007/s00384-013-1801-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study was to investigate telephone follow-up of post-endoscopy patients as an alternative to attendance at the outpatient department. METHODS Access to outpatient appointments is often a target for improvement in healthcare systems. Increased outpatient clinic capacity is not feasible without investment and extra manpower in an already constrained service. Outpatient attendance was audited at a busy colorectal surgical service. A subset of patients appropriate for follow-up in a "virtual outpatient department" (VOPD) were identified. A pilot study was designed and involved telephone follow-up of low-risk endoscopic procedures. Patient satisfaction was assessed using the Medical Interview Satisfaction Scale (MISS), which is a standardised survey of patient satisfaction with healthcare experiences. This was conducted via anonymous questionnaire at the end of the study. RESULTS Of a total of 166 patients undergoing endoscopy in the time period, 79 were prospectively recruited to VOPD follow-up based on eligibility criteria. Overall, 67 (84.8 %) were successfully followed up by telephone consultation; nine patients (11.4 %) were contacted by mail. The remaining three patients (3.8 %) were brought back to the OPD. Patients recruited were more likely to be younger (55.82 ± 14.96 versus 60.78 ± 13.97 years, P = 0.029) and to have had normal examinations (49.4 versus 31.0 %, χ (2) = 5.070, P = 0.025). Nearly three quarters of patients responded to the questionnaire. The mean scores for all four aspects of the MISS were satisfactory, and overall patients were satisfied with the VOPD experience. CONCLUSION VOPD is a target for improved healthcare provision, with improved efficiency and a high patient satisfaction rate.
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Affiliation(s)
- Elizabeth M Ryan
- Department of Colorectal Surgery, Beaumont Hospital, Beaumont, Dublin 9, Ireland
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Scherpbier-de Haan ND, van Gelder VA, Van Weel C, Vervoort GMM, Wetzels JFM, de Grauw WJC. Initial implementation of a web-based consultation process for patients with chronic kidney disease. Ann Fam Med 2013; 11:151-6. [PMID: 23508602 PMCID: PMC3601384 DOI: 10.1370/afm.1494] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE A Web-based consultation system (telenephrology) enables family physicians to consult a nephrologist about a patient with chronic kidney disease. Relevant data are exported from the patient's electronic file to a protected digital environment from which advice can be formulated by the nephrologist. The primary purpose of this study was to assess the potential of telenephrology to reduce in-person referrals. METHODS In an observational, prospective study, we analyzed telenephrology consultations by 28 family practices and 5 nephrology departments in the Netherlands between May 2009 and August 2011. The primary outcome was the potential reduction of in-person referrals, measured as the difference between the number of intended referrals as stated by the family physician and the number of referrals requested by the nephrologist. The secondary outcome was the usability of the system, expressed as time invested, the implementation in daily work hours, and the response time. Furthermore, we evaluated the questions asked. RESULTS One hundred twenty-two new consultations were included in the study. In the absence of telenephrology, 43 patients (35.3%) would have been referred by their family physicians, whereas the nephrologist considered referral necessary in only 17 patients (13.9%) (P <.001). The family physician would have treated 79 patients in primary care. The nephrologist deemed referral necessary for 10 of these patients. Time investment per consultation amounted to less than 10 minutes. Consultations were mainly performed during office hours. Response time was 1.6 days (95% CI, 1.2-1.9 days). Most questions concerned estimated glomerular filtration rate, proteinuria, and blood pressure. CONCLUSION A Web-based consultation system might reduce the number of referrals and is usable. Telenephrology may contribute to an effective use of health facilities by allowing patients to be treated in primary care with remote support by a nephrologist.
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Affiliation(s)
- Nynke D Scherpbier-de Haan
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.
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Patel PB, Vinson DR. Physician e-mail and telephone contact after emergency department visit improves patient satisfaction: a crossover trial. Ann Emerg Med 2013; 61:631-7. [PMID: 23465304 DOI: 10.1016/j.annemergmed.2012.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 11/18/2012] [Accepted: 11/27/2012] [Indexed: 12/27/2022]
Abstract
STUDY OBJECTIVE Enhancing emergency department (ED) patient satisfaction has wide-ranging benefits. We seek to determine how postvisit patient-physician contact by e-mail or telephone affects patients' satisfaction with their emergency physician. METHODS We undertook this crossover study from May 1, 2010, to June 30, 2010, at 2 community EDs. Forty-two physicians either e-mailed or telephoned their patients within 72 hours of the ED visit for 1 month; in the alternate month, they provided no contact, serving as their own controls. Patients received satisfaction surveys after their ED visit. Patient satisfaction is reported as a percentage of those responding very good or excellent on a 5-point Likert scale for 3 questions about their emergency physician's skills, care, and communication. We calculated differences between patient groups (noncontact versus contact) using an intention-to-treat analysis. RESULTS The mean patient satisfaction score was 79.4% for the 1,002 patients in the noncontact group and 87.7% for the 348 patients in the contact group (difference 8.3%; 95% confidence interval 4.0% to 12.6%). Patient satisfaction scores were similar for e-mail and telephone contact: 89.3% for the e-mail group and 85.2% for the telephone group (difference 4.1%; 95% confidence interval -2.3% to 10.5%). CONCLUSION Patient satisfaction was higher when emergency physicians contacted patients briefly after their visit, either by e-mail or by telephone. Higher patient satisfaction was observed equally among patients contacted by e-mail and those contacted by telephone. Postvisit patient-physician contact could be a valuable practice to improve ED patient satisfaction.
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Affiliation(s)
- Pankaj B Patel
- Department of Emergency Medicine, The Permanente Medical Group, Kaiser Permanente Medical Centers, Sacramento and Roseville, CA, USA.
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Trochez R, Harber P, Holmes D. Is postal postoperative follow-up in urogynaecology feasible? J OBSTET GYNAECOL 2013; 32:663-5. [PMID: 22943713 DOI: 10.3109/01443615.2012.713051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Postoperative follow-up after urogynaecological surgery has been little investigated. Traditionally, it is done in hospital but there is wide variation in the assessments and timing. We aimed to determine the viability of postal follow-up in women undergoing urogynaecological surgery. This is a retrospective review of prospectively collected data. All women who underwent prolapse and/or urinary incontinence surgery between January and June 2010 were included. Validated ICIQ questionnaires for prolapse and/or incontinence, as appropriate, were used, before surgery and at 6 months postoperatively. The primary outcome was the response rate to postal follow-up. A total of 70 women had urogynaecology surgery during the study period; 65 (93%) women returned the questionnaires (95% CI 84-97%, p < 0.0001). The postoperative questionnaires scores showed a statistically significant improvement compared with the preoperative scores. This results in only a small proportion of women needing hospital attendance for follow-up (10%). We conclude that postal follow-up is feasible.
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Affiliation(s)
- R Trochez
- Department of Urogynaecology, Liverpool Women's NHS Trust, Liverpool.
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Coleman NE, Pon S. Quality: performance improvement, teamwork, information technology and protocols. Crit Care Clin 2013; 29:129-51. [PMID: 23537668 DOI: 10.1016/j.ccc.2012.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Using the Institute of Medicine framework that outlines the domains of quality, this article considers four key aspects of health care delivery which have the potential to significantly affect the quality of health care within the pediatric intensive care unit. The discussion covers: performance improvement and how existing methods for reporting, review, and analysis of medical error relate to patient care; team composition and workflow; and the impact of information technologies on clinical practice. Also considered is how protocol-driven and standardized practice affects both patients and the fiscal interests of the health care system.
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Affiliation(s)
- Nana E Coleman
- Division of Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, 525 East 68th Street, M-508, New York, NY 10065-4870, USA
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Affiliation(s)
- Alison F McGill
- Princess Alexandra Hospital, Sydney, New South Wales, Australia
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Abstract
The enormous diversity of physician practices, including specialists, and patient requirements and comorbidities make integration of appropriate perioperative information difficult. Lack of communicating computer systems adds to the difficulty of assembling data. Meta analysis and evidence-based studies indicate that far too many tests are performed perioperatively. Guidelines for appropriate perioperative management have been formulated by several specialties. Education as to current findings and requirements should be better communicated to surgeons, consultants, and patients to improve healthcare needs and at the same time decrease costs. Means to better communication by interpersonal collaboration are outlined.
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Matthews GA, Dumville JC, Hewitt CE, Torgerson DJ. Retrospective cohort study highlighted outcome reporting bias in UK publicly funded trials. J Clin Epidemiol 2011; 64:1317-24. [PMID: 21889307 DOI: 10.1016/j.jclinepi.2011.03.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 02/25/2011] [Accepted: 03/22/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess outcome reporting bias and dissemination bias in trials funded by the National Health System (NHS) Health Technology Assessment (HTA) program. STUDY DESIGN AND SETTING A retrospective cohort study of HTA monographs and corresponding journal publications including all clinical effectiveness randomized controlled trials published as HTA monographs between 1999 and 2005 by the NHS HTA program. RESULTS There was a higher median P-value (P=0.33, interquartile range [IQR]: 0.02-0.54) among trials without a journal publication compared with those with a journal publication (P=0.14, IQR: 0.007-0.43), although the difference was not statistically significant (Mann-Whitney U test, z=-0.70; P=0.48). A higher proportion of statistically significant findings were reported in journal articles when compared with the outcomes reported in the HTA monographs. Trials published in general medical journals tended to have smaller P-values (median: 0.05, IQR: 0.001-0.22) than those published in more specialist journals (median: 0.33 IQR: 0.008-0.58), although this result was not significant (Mann-Whitney U test, z=-1.63; P=0.10). CONCLUSIONS Among journal-published trials, there were a greater proportion of statistically significant findings included in the journal reports compared with those in the HTA monographs.
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Harvey S, Peterkin G, Wootton R. Eleven years of experience with low-bandwidth telemedicine in a nurse-led rural clinic in Scotland. J Telemed Telecare 2010; 16:417-21. [PMID: 20876630 DOI: 10.1258/jtt.2010.100310] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A pilot trial of telemedicine in primary care began in the village of Letham in 1998. The service provided conventional consultations with the district nurse, plus teleconsultations with a general practitioner (GP) at the health centre in Forfar, a few km away. In the first year, the videoconferencing link was used by 14 patients, all aged over 65 years. The telemedicine service was judged to be successful and subsequently expanded to patients of any age. It was used for a wide range of health matters, including postnatal care, mental health problems, physical ailments, receiving test results and discussions with the doctor. During the 11-year study period, a total of 646 teleconsultations were conducted, a median rate of 65 per year. A qualitative evaluation of the service was conducted in 1999. Although the GPs involved expressed some reservations about the limited video quality, all three user groups were positive about the service. Nonetheless, the telemedicine service was not adopted as a routine method of health-care delivery by the NHS. To enable any telemedicine application to move from the pilot trial stage to routine service requires several things to happen at an organisational and contractual level. Ultimately an organizational decision about adoption is required, followed by appropriate mechanisms to enable diffusion.
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Affiliation(s)
- Sylvia Harvey
- Academy Medical Centre, Academy Street, Forfar DD8 2HA, UK.
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Akbari A, Mayhew A, Al-Alawi MA, Grimshaw J, Winkens R, Glidewell E, Pritchard C, Thomas R, Fraser C. Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database Syst Rev 2008; 2008:CD005471. [PMID: 18843691 PMCID: PMC4164370 DOI: 10.1002/14651858.cd005471.pub2] [Citation(s) in RCA: 154] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The primary care specialist interface is a key organisational feature of many health care systems. Patients are referred to specialist care when investigation or therapeutic options are exhausted in primary care and more specialised care is needed. Referral has considerable implications for patients, the health care system and health care costs. There is considerable evidence that the referral processes can be improved. OBJECTIVES To estimate the effectiveness and efficiency of interventions to change outpatient referral rates or improve outpatient referral appropriateness. SEARCH STRATEGY We conducted electronic searches of the Cochrane Effective Practice and Organisation of Care (EPOC) group specialised register (developed through extensive searches of MEDLINE, EMBASE, Healthstar and the Cochrane Library) (February 2002) and the National Research Register. Updated searches were conducted in MEDLINE and the EPOC specialised register up to October 2007. SELECTION CRITERIA Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series of interventions to change or improve outpatient referrals. Participants were primary care physicians. The outcomes were objectively measured provider performance or health outcomes. DATA COLLECTION AND ANALYSIS A minimum of two reviewers independently extracted data and assessed study quality. MAIN RESULTS Seventeen studies involving 23 separate comparisons were included. Nine studies (14 comparisons) evaluated professional educational interventions. Ineffective strategies included: passive dissemination of local referral guidelines (two studies), feedback of referral rates (one study) and discussion with an independent medical adviser (one study). Generally effective strategies included dissemination of guidelines with structured referral sheets (four out of five studies) and involvement of consultants in educational activities (two out of three studies). Four studies evaluated organisational interventions (patient management by family physicians compared to general internists, attachment of a physiotherapist to general practices, a new slot system for referrals and requiring a second 'in-house' opinion prior to referral), all of which were effective. Four studies (five comparisons) evaluated financial interventions. One study evaluating change from a capitation based to mixed capitation and fee-for-service system and from a fee-for-service to a capitation based system (with an element of risk sharing for secondary care services) observed a reduction in referral rates. Modest reductions in referral rates of uncertain significance were observed following the introduction of the general practice fundholding scheme in the United Kingdom (UK). One study evaluating the effect of providing access to private specialists demonstrated an increase in the proportion of patients referred to specialist services but no overall effect on referral rates. AUTHORS' CONCLUSIONS There are a limited number of rigorous evaluations to base policy on. Active local educational interventions involving secondary care specialists and structured referral sheets are the only interventions shown to impact on referral rates based on current evidence. The effects of 'in-house' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising.
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Affiliation(s)
- Ayub Akbari
- Department of Medicine/Division of Nephrology, Kidney Research Center/University of Ottawa, Ottawa Hospital, Riverside Hospitall, 1967 Rverside Drive, Suite 5-25, Ottawa, Ontario, Canada, K1H 7W9.
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De Rouck S, Jacobs A, Leys M. A methodology for shifting the focus of e-health support design onto user needs. Int J Med Inform 2008; 77:589-601. [DOI: 10.1016/j.ijmedinf.2007.11.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2007] [Revised: 09/09/2007] [Accepted: 11/19/2007] [Indexed: 11/28/2022]
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Koivunen M, Hätönen H, Välimäki M. Barriers and facilitators influencing the implementation of an interactive Internet-portal application for patient education in psychiatric hospitals. PATIENT EDUCATION AND COUNSELING 2008; 70:412-419. [PMID: 18079085 DOI: 10.1016/j.pec.2007.11.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2007] [Revised: 10/11/2007] [Accepted: 11/01/2007] [Indexed: 05/25/2023]
Abstract
OBJECTIVE The purpose of this study was to identify barriers and facilitators influencing the implementation of an interactive Internet-portal application for patient education in psychiatric hospitals. METHODS The data were collected from nurses by means of a questionnaire with thematic open-ended questions. The data was analysed using qualitative content analysis. RESULTS Four main categories were formed to describe barriers and facilitators of portal implementation in psychiatric wards. These categories were organisational resources, nurses' individual characteristics, patient-related factors and portal-related factors. Some major barriers were identified restricting the use of the portal in patient education: lack of computers, lack of time for patients, nurses' negative attitudes towards computer use and lack of education. The main facilitators for portal use were appropriate technological resources, easy Internet access, enough time for portal use, and level of motivation among staff to use computers. CONCLUSION The specific challenge in achieving patient education with the computer in psychiatric care is to ensure technological resources and that the staff are motivated to use computers. At the same time, attention should be paid the relationship between patient and nurse. PRACTICE IMPLICATIONS It is important to examine the patient-nurse relationship in the education process and also to define the usability of the application from the patients' point of view.
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Affiliation(s)
- Marita Koivunen
- Satakunta Hospital District and University of Turku, Department of Nursing Science, Turku, Finland.
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40
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Dowie R, Mistry H, Young TA, Weatherburn GC, Gardiner HM, Rigby M, Rowlinson GV, Franklin RCG. Telemedicine in pediatric and perinatal cardiology: Economic evaluation of a service in English hospitals. Int J Technol Assess Health Care 2007; 23:116-25. [PMID: 17234025 DOI: 10.1017/s0266462307051653] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Objectives:Pediatric cardiology has an expanding role in fetal and pediatric screening. The aims of this study were to observe how district hospitals use a pediatric telecardiology service, and to compare the costs and outcomes of patients referred to specialists by means of this service or conventionally.Methods:A telemedicine service was set up between a pediatric cardiac center in London and four district hospitals for referrals of second trimester women, newborn babies, and older children. Clinicians in each hospital decided on the role for their service. Clinical events were audited prospectively and costed, and patient surveys were conducted.Results:The hospitals differed in their selection of patient groups for the service. In all, 117 telemedicine patients were compared with 387 patients seen in London or in outreach clinics. Patients selected for telemedicine were generally healthier. For all patients, the mean cost for the initial consultation was £411 for tele-referrals and £277 for conventional referrals, a nonsignificant difference. Teleconsultations for women and children were significantly more expensive because of technology costs, whereas for babies, ambulance transfers were much more costly. After 6-months follow-up, the difference between referral methods for all patients was nonsignificant (telemedicine, £3,350; conventional referrals, £2,172), and nonsignificant within the patient groups.Conclusions:Telemedicine was perceived by cardiologists, district clinicians, and families as reliable and efficient. The equivocal 6-month cost results indicate that investment in the technology is warranted to enhance pediatric and perinatal cardiology services.
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Affiliation(s)
- Robin Dowie
- Health Economics Research Group, Brunel University, Uxbridge, Middlesex, UK.
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41
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May C. A rational model for assessing and evaluating complex interventions in health care. BMC Health Serv Res 2006; 6:86. [PMID: 16827928 PMCID: PMC1534030 DOI: 10.1186/1472-6963-6-86] [Citation(s) in RCA: 250] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2006] [Accepted: 07/07/2006] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Understanding how new clinical techniques, technologies and other complex interventions become normalized in practice is important to researchers, clinicians, health service managers and policy-makers. This paper presents a model of the normalization of complex interventions. METHODS Between 1995 and 2005 multiple qualitative studies were undertaken. These examined: professional-patient relationships; changing patterns of care; the development, evaluation and implementation of telemedicine and related informatics systems; and the production and utilization of evidence for practice. Data from these studies were subjected to (i) formative re-analysis, leading to sets of analytic propositions; and to (ii) a summative analysis that aimed to build a robust conceptual model of the normalization of complex interventions in health care. RESULTS A normalization process model that enables analysis of the conditions necessary to support the introduction of complex interventions is presented. The model is defined by four constructs: interactional workability; relational integration; skill set workability and contextual integration. This model can be used to understand the normalization potential of new techniques and technologies in healthcare settings CONCLUSION The normalization process model has face validity in (i) assessing the potential for complex interventions to become routinely embedded in everyday clinical work, and (ii) evaluating the factors that promote or inhibit their success and failure in practice.
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Affiliation(s)
- Carl May
- Institute of Health and Society, Newcastle University, 21 Claremont Place, Newcastle upon Tyne, NE2 4AA, UK.
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Grimshaw JM, Winkens RAG, Shirran L, Cunningham C, Mayhew A, Thomas R, Fraser C. Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database Syst Rev 2005:CD005471. [PMID: 16034981 DOI: 10.1002/14651858.cd005471] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The primary care specialist interface is a key organisational feature of many health care systems. Patients are referred to specialist care when investigation or therapeutic options are exhausted in primary care and more specialised care is needed. Referral has considerable implications for patients, the health care system and health care costs. There is considerable evidence that the referral processes can be improved. OBJECTIVES To estimate the effectiveness and efficiency of interventions to change outpatient referral rates or improve outpatient referral appropriateness. SEARCH STRATEGY We conducted electronic searches of the Cochrane Effective Practice and Organisation of Care (EPOC) group specialised register (developed through extensive searches of MEDLINE, EMBASE, Healthstar and the Cochrane Library) (February 2002) and the National Research Register. SELECTION CRITERIA Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series of interventions to change or improve outpatient referrals. Participants were primary care physicians. The outcomes were objectively measured provider performance or health outcomes. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted data and assessed study quality. MAIN RESULTS Seventeen studies involving 23 separate comparisons were included. Nine studies (14 comparisons) evaluated professional educational interventions. Ineffective strategies included: passive dissemination of local referral guidelines (two studies), feedback of referral rates (one study) and discussion with an independent medical adviser (one study). Generally effective strategies included dissemination of guidelines with structured referral sheets (four out of five studies) and involvement of consultants in educational activities (two out of three studies). Three studies evaluated organisational interventions (patient management by family physicians compared to general internists, attachment of a physiotherapist to general practices and requiring a second 'in-house' opinion prior to referral), all of which were effective. Five studies (six comparisons) evaluated financial interventions. Two studies evaluating change from a capitation based to mixed capitation and fee-for-service system and from a fee-for-service to a capitation based system (with an element of risk sharing for secondary care services) observed a reduction in referral rates. Modest reductions in referral rates of uncertain significance were observed following the introduction of the general practice fundholding scheme in the United Kingdom (UK). One study evaluating the effect of providing access to private specialists demonstrated an increase in the proportion of patients referred to specialist services but no overall effect on referral rates. AUTHORS' CONCLUSIONS There are a limited number of rigorous evaluations to base policy on. Active local educational interventions involving secondary care specialists and structured referral sheets are the only interventions shown to impact on referral rates based on current evidence. The effects of 'in-house' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising.
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Affiliation(s)
- J M Grimshaw
- Ottawa Health Research Institute, 1053 Carling Avenue, Administration Building, Room 2-017, Ottawa, Ontario, Canada, AB25 2ZD.
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