Telemedicine: Embracing virtual care during COVID-19 pandemic

Increased Virtual Visits to Physicians During the COVID-19 Pandemic and Estimated Impact on Physician Compensation: The Case of Lung and Colorectal Cancers, Chronic Obstructive Pulmonary Diseases, and Heart Failure in Alberta, Canada

Introduction: The COVID-19 pandemic started in Alberta in March 2020 and significantly increased telehealth service use and provision reducing the risk of virus transmission. We examined the change in the number and proportion of virtual visits by physician specialty and condition (chronic obstructive pulmonary diseases [COPD], heart failure [HF], colorectal and lung cancers), as well as associated changes in physician compensation. Methods: A population-based design was used to analyze all processed physician claims comparing the number and proportion of virtual visits and associated physician billings relative to in-person between pre- (2019/2020) and intra-pandemic (2020/2021). Physician compensations were the claim amounts paid by the health insurance. Results: Pre-pandemic (intra-), there were 8,981 (8,897) lung cancer, 9,245 (9,029) colorectal, 37,558 (36,292) HF, and 68,270 (52,308) COPD patients. Each patient had totally 2.3-4.7 (of which 0.4-0.6% were virtual) general practitioner (GP) visits and 0.9-2.3 (0.2-0.7% were virtual) specialist visits per year pre-pandemic. The average number and proportion of per-patient virtual visits to GPs and specialists grew significantly pre- to intra-pandemic by 2,138-4,567%, and 2,201-7,104%, respectively. Given the lower fees of virtual compared with in-person visits, the reduction in physician compensation associated with the increased use of virtual care was estimated at $3.85 million, with $2.44 million attributed to specialist and $1.41 million to GP. Discussion: Utilization of telehealth increased significantly, while the physician billings per patient and physician compensation declined early in the pandemic in Alberta for the four chronic diseases considered. This study forms the basis for future study in understanding the impact of virtual care, now part of the fabric of health care delivery, on quality of care and patient safety, overall health service utilization (such as diagnostic imaging and other investigations), as well as economic impacts to patients, health care systems, and society.

Virtual care during COVID-19: The perspectives of older adults and their healthcare providers in a cardiac rehabilitation setting

The present study aimed to explore the perspectives of older adults and health providers on cardiac rehabilitation care provided virtually during COVID-19. A qualitative exploratory methodology was used. Semi-structured interviews were conducted with 15 older adults and 6 healthcare providers. Five themes emerged from the data: (1) Lack of emotional intimacy when receiving virtual care, (2) Inadequacy of virtual platforms, (3) Saving time with virtual care, (4) Virtual care facilitated accessibility, and (5) Loss of connections with patients and colleagues. Given that virtual care continues to be implemented, and in some instances touted as an optimal option for the delivery of cardiac rehabilitation, it is critical to address the needs of older adults living with cardiovascular disease and their healthcare providers. This is particularly crucial related to issues accessing and using technology, as well as older adults' need to build trust and emotional connection with their providers.

Effect of mode of healthcare delivery on job satisfaction and intention to quit among nurses in Canada during the COVID-19 pandemic

The COVID-19 pandemic resulted in a major shift in the delivery of healthcare services with the adoption of care modalities to address the diverse needs of patients. Besides, nurses, the largest profession in the healthcare sector, were imposed with challenges caused by the pandemic that influenced their intention to leave their profession. The aim of the study was to examine the influence of mode of healthcare delivery on nurses' intention to quit job due to lack of satisfaction during the pandemic in Canada. This cross-sectional study utilized data from the Health Care Workers' Experiences During the Pandemic (SHCWEP) survey, conducted by Statistics Canada, that targeted healthcare workers aged 18 and over who resided in the ten provinces of Canada during the COVID-19 pandemic. The main outcome of the study was nurses' intention to quit within two years due to lack of job satisfaction. The mode of healthcare delivery was categorized into; in-person, online, or blended. Multivariable logistic regression was performed to examine the association between mode of healthcare delivery and intention to quit job after adjusting for sociodemographic, job-, and health-related factors. Analysis for the present study was restricted to 3,430 nurses, weighted to represent 353,980 Canadian nurses. Intention to quit job, within the next two years, due to lack of satisfaction was reported by 16.4% of the nurses. Results showed that when compared to participants who provided in-person healthcare services, those who delivered online or blended healthcare services were at decreased odds of intention to quit their job due to lack of job satisfaction (OR = 0.47, 95% CI: 0.43-0.50 and OR = 0.64, 95% CI: 0.61-0.67, respectively). Findings from this study can inform interventions and policy reforms to address nurses' needs and provide organizational support to enhance their retention and improve patient care during times of crisis.

Improving access to care for underserved communities through telemedicine

ABSTRACT

Telemedicine use expanded rapidly during the COVID-19 pandemic, giving patients access to quality care while reducing the spread of infection. Although beneficial changes were made to reimbursement and privacy guidelines to increase the ease of telemedicine for clinicians, the lack of digital devices, Internet, digital knowledge, and trust in this method of delivery are potential barriers to telemedicine for healthcare visits, and may have widened the care gap for underserved patients. To ensure that patients of all socioeconomic levels have access to telemedicine requires education, expanding broadband Internet access across the United States, and offering free or reduced Internet services to patients in need.

Insights from an Exploratory Retrospective Cohort Study: Are Face-to-Face Follow-Up Consultations after Colonoscopy a Thing of the Past?

BACKGROUND

Colonoscopy is a commonly performed procedure, but most patients will not actually be found with colorectal cancer. Subsequent face-to-face consultations to explain post-colonoscopy findings are common despite the time and cost-saving benefits of teleconsultation, especially in a post-COVID-19 era. This exploratory retrospective study examined the proportion of post-colonoscopy follow-up consultations that could have been converted to teleconsultation within a tertiary hospital in Singapore.

METHODS

A retrospective cohort of all patients who underwent colonoscopy in the institution from July to September 2019 was identified. All follow-up face-to-face consultations related to the index colonoscopy from the scope date to 6 months post-colonoscopy were traced. Clinical data relevant to the index colonoscopy and these consultations were extracted from electronic medical records.

RESULTS

The cohort consisted of 859 patients (68.5% male, age range: 18-96 years). Of these, 15 (1.7%) had colorectal cancer, but the majority (n = 643, 74.9%) were scheduled for at least one post-colonoscopy visit - a total of 884 face-to-face clinical visits. The final sample was 682 (77.1%) face-to-face post-colonoscopy visits that did not involve any procedures performed or indicated the need for any subsequent follow-up.

CONCLUSION

If such "unnecessary" post-colonoscopy consultations exist within our institution, then similar situations possibly occur elsewhere. As COVID-19 continues to periodically tax healthcare systems worldwide, preservation of resources will remain integral alongside quality standards of routine patient care. There is a need for detailed analyses and modeling to hypothesize potential savings by also considering the start-up and maintenance costs of switching to a teleconsultation-dominated system.

Experiences on the Utility and Barriers of Telemedicine in Healthcare Delivery in Kenya

Introduction

Telemedicine is the provision of health services over a distance using information communication technology devices. Telemedicine is emerging as a promising component of healthcare care delivery worldwide, accelerated by the COVID-19 pandemic. This study assessed the factors promoting uptake, barriers, and opportunities for telemedicine among doctors in Kenya. Methodology. A semiquantitative, cross-sectional online survey was conducted among doctors in Kenya. During a month, between February and March 2021, 1,200 doctors were approached by email and WhatsApp, of whom 13% responded. Findings. A total of 157 interviewees participated in the study. The general usage of telemedicine was 50%. Seventy-three percent of doctors reported using a mix of in-person care and telemedicine. Fifty percent reported using telemedicine to support physician-to-physician consultations. Telemedicine had limited utility as a standalone clinical service. The inadequate information communication technology infrastructure was the most reported barrier to telemedicine, followed by a cultural resistance to using technology to deliver healthcare services. Other notable barriers were the high cost of initial setup limited skills among patients, limited skills among doctors, inadequate funding to support telemedicine services, weak legislative/policy framework, and lack of dedicated time for telemedicine services. The COVID-19 pandemic increased the uptake of telemedicine in Kenya.

Conclusion

The most extensive use of telemedicine in Kenya supports physician-to-physician consultations. There is limited single use of telemedicine in providing direct clinical services to patients. However, telemedicine is regularly used in combination with in-person clinical services, allowing for continuity of clinical services beyond the physical hospital infrastructure. With the widespread adoption of digital technologies in Kenya, especially mobile telephone technologies, the growth opportunities for telemedicine services are immense. Numerous mobile applications will improve access capabilities for both service providers and users and bridge the gaps in care.

Service delivery challenges in HIV care during the first year of the COVID-19 pandemic: results from a site assessment survey across the global IeDEA consortium

INTRODUCTION

Interruptions in treatment pose risks for people with HIV (PWH) and threaten progress in ending the HIV epidemic; however, the COVID-19 pandemic's impact on HIV service delivery across diverse settings is not broadly documented.

METHODS

From September 2020 to March 2021, the International epidemiology Databases to Evaluate AIDS (IeDEA) research consortium surveyed 238 HIV care sites across seven geographic regions to document constraints in HIV service delivery during the first year of the pandemic and strategies for ensuring care continuity for PWH. Descriptive statistics were stratified by national HIV prevalence (<1%, 1-4.9% and ≥5%) and country income levels.

RESULTS

Questions about pandemic-related consequences for HIV care were completed by 225 (95%) sites in 42 countries with low (n = 82), medium (n = 86) and high (n = 57) HIV prevalence, including low- (n = 57), lower-middle (n = 79), upper-middle (n = 39) and high- (n = 50) income countries. Most sites reported being subject to pandemic-related restrictions on travel, service provision or other operations (75%), and experiencing negative impacts (76%) on clinic operations, including decreased hours/days, reduced provider availability, clinic reconfiguration for COVID-19 services, record-keeping interruptions and suspension of partner support. Almost all sites in low-prevalence and high-income countries reported increased use of telemedicine (85% and 100%, respectively), compared with less than half of sites in high-prevalence and lower-income settings. Few sites in high-prevalence settings (2%) reported suspending antiretroviral therapy (ART) clinic services, and many reported adopting mitigation strategies to support adherence, including multi-month dispensing of ART (95%) and designating community ART pick-up points (44%). While few sites (5%) reported stockouts of first-line ART regimens, 10-11% reported stockouts of second- and third-line regimens, respectively, primarily in high-prevalence and lower-income settings. Interruptions in HIV viral load (VL) testing included suspension of testing (22%), longer turnaround times (41%) and supply/reagent stockouts (22%), but did not differ across settings.

CONCLUSIONS

While many sites in high HIV prevalence settings and lower-income countries reported introducing or expanding measures to support treatment adherence and continuity of care, the COVID-19 pandemic resulted in disruptions to VL testing and ART supply chains that may negatively affect the quality of HIV care in these settings.

COVID-19 associated changes in HIV service delivery over time in Central Africa: Results from facility surveys during the first and second waves of the pandemic

INTRODUCTION

The COVID-19 pandemic has impacted population health around the globe, directly and indirectly. The objective of this study was to document changes in HIV care associated with the COVID-19 pandemic at selected clinics in Central Africa, along with clinic-level strategies for minimizing disruptions in HIV care and treatment for people with HIV (PWH).

METHODS

A 51-item questionnaire on COVID-19 pandemic-associated changes in HIV service delivery was completed by clinicians involved in HIV care at 21 clinics in five countries participating in Central Africa International epidemiology Databases to Evaluate AIDS (CA-IeDEA). The survey was completed at two timepoints: June-July 2020 and October 2020 to February 2021. Descriptive statistics were used to characterize changes in HIV care and related services.

RESULTS

While 81% of sites reported at least one negative consequence of COVID-19 for clinic operations during the first survey, none reported suspending antiretroviral therapy (ART) initiation services for new patients, and 24% reported adopting telemedicine. In the follow-up survey, fewer sites (48%) reported at least one disruption to clinic operations, and more sites reported mitigation strategies, including expanding rapid ART initiation services and providing extra supplies of ART medications to reduce visit frequency. In the follow-up survey, more sites, especially in Rwanda, reported stockouts of commodities, including HIV and viral load testing and HIV pre-exposure prophylaxis. More than one-fifth of sites reported stockouts of second- or third-line ART at each survey timepoint.

CONCLUSIONS

While the initial wave of the COVID-19 pandemic resulted in concerning disruptions to HIV service delivery at CA-IeDEA sites, most of these disruptions attenuated over time, and many sites introduced measures to help PWH avoid frequent visits to the clinic for care and medications. The impact of HIV commodity stockouts and clinic mitigation strategies on treatment outcomes needs to be assessed.

COVID-19 and hospice community palliative care in New Zealand: A qualitative study

Within the context of an ageing population and the added challenges posed by COVID-19, the need to optimise palliative care management in the community - the setting where a significant proportion of people prefer to die - cannot be underestimated. To date, there has been a dearth of research exploring community palliative care delivery during the pandemic. This study aimed to explore the impact of and response to COVID-19 for hospice community services in Aotearoa/New Zealand. Eighteen structured interviews were conducted (10 February-18 August 2021) with healthcare professionals from sixteen purposively sampled community hospices from New Zealand regions according to the number of COVID-19-positive patients per 100,000 inhabitants (low, medium and high) with oversampling of high prevalence areas. Two overarching themes emerged 'challenges' and 'adaptations'. Each theme had several subthemes related to service delivery in communication, visiting, allied health team collaboration and volunteer services. Adaptations involved adjusting official health advice to the local context, increased use of telehealth, reducing infection risk during in-home visits through triaging of cases, division of the workforce into teams and repurposing volunteers' services. Despite these adaptations, challenges remained, including increased workload pressures for staff and an absence of the human touch for patients and families. Implications for hospice practice and recommendations for future research are discussed. Governments must acknowledge the essential contribution of hospice to the COVID-19 pandemic and ensure that these services are incorporated into the healthcare system response.

Telehealth solutions for assessing auditory outcomes related to noise and ototoxic exposures in clinic and research

Nearly 1.5 billion people globally have some decline in hearing ability throughout their lifetime. Many causes for hearing loss are preventable, such as that from exposure to noise and chemicals. According to the World Health Organization, nearly 50% of individuals 12-25 years old are at risk of hearing loss due to recreational noise exposure. In the occupational setting, an estimated 16% of disabling hearing loss is related to occupational noise exposure, highest in developing countries. Ototoxicity is another cause of acquired hearing loss. Audiologic assessment is essential for monitoring hearing health and for the diagnosis and management of hearing loss and related disorders (e.g., tinnitus). However, 44% of the world's population is considered rural and, consequently, lacks access to quality hearing healthcare. Therefore, serving individuals living in rural and under-resourced areas requires creative solutions. Conducting hearing assessments via telehealth is one such solution. Telehealth can be used in a variety of contexts, including noise and ototoxic exposure monitoring, field testing in rural and low-resource settings, and evaluating auditory outcomes in large-scale clinical trials. This overview summarizes current telehealth applications and practices for the audiometric assessment, identification, and monitoring of hearing loss.

SPARSH electronic sub-health centers (e-SHCs) - A model of nurse-run SHCs supported by general practitioners through telemedicine

Background

The primary health care services in India suffer from inconsistent availability of providers, lack of quality, poor availability of medicines and diagnostics, and a poorly functioning referral linkage. A multi-pronged approach is required to address these issues.

Methods

We describe here a model of electronic sub-health centers (e-SHCs) managed by trained nurses supported by a general practitioner over telemedicine. The e-SHCs are expected to meet two objectives - 1) to create a point of comprehensive primary health care delivery at an affordable cost and 2) to create a referral support system backed by information technology and physical movement.

Results

The model is described in nine sections - service delivery framework, human resources, diagnostics, infrastructure, quality improvement, health management information system, materials management, financing, and branding. It is a video-based real-time (synchronous) health worker to the registered medical practitioner telemedicine facility. The model has been compared with five other telemedicine and five other tele-rehabilitation models.

Conclusion

Although there are inherent challenges to operationalize this model, it also presents a unique opportunity of testing an innovative approach of providing quality primary health care at an affordable cost. The process will generate learnings for addressing the primary care health care delivery gaps in the country.

Use of E-Health in Dutch General Practice during the COVID-19 Pandemic

The COVID-19 pandemic has forced general practices to search for possibilities to provide healthcare remotely (e.g., e-health). In this study, the impact of the pandemic on the use of e-health in general practices in the Netherlands was investigated. In addition, the intention of practices to continue using e-health more intensively and differences in the use of e-health between practice types were investigated. For this purpose, web surveys were sent to general practices in April and July 2020. Descriptive data analysis was performed and differences in the use of e-health between practice types were tested using one-way ANOVA. Response rates were 34% (n = 1433) in April and 17% (n = 719) in July. The pandemic invoked an increased use of several (new) e-health applications. A minority of practices indicated the intention to maintain this increased use. In addition, small differences in the use of e-health between the different practice types were found. This study showed that although there was an increased uptake of e-health in Dutch general practice during the COVID-19 pandemic, only a minority of practices intends to maintain this increased use in the future. This may point towards a temporary uptake of digital healthcare delivery rather than accelerated implementation of digital processes.

Is Hybrid Telehealth Model the Next Step for Private Healthcare in India?

Irrespective of geography, the implementation of telehealth has been one of the biggest changes caused by the COVID-19 pandemic. Post the pandemic, telehealth will continue to be part of mainstream health service delivery but in a different format. This commentary investigates the hybrid model of telehealth in India. A hybrid model can help India provide accessible and affordable healthcare to a wider part of its population and support the already growing medical tourism industry. The challenges to this revolve around digital education for patients and providers, integration of technology into existing care pathways, infrastructural investment and in creating seamless systems. It is a scalable and profitable model that must be seriously considered in the post pandemic world.

Attitudes and perceptions of outpatients towards adoption of telemedicine in healthcare during COVID-19 pandemic

BACKGROUND

Asia is home to a burgeoning market for telemedicine with the availability of cheaper smartphones and internet services. Due to a rise in telemedicine use by doctors and patients, it is imperative to understand the perception of patients towards the adoption of telemedicine, the availability of telemedicine to the general population, the frequency with which patients avail these services, and the motivation or apprehensions in using them, especially during the COVID-19 pandemic.

AIMS

The study is performed to understand the behavioral attitude and perceptions of the population regarding telemedicine and, in doing so, make services more user-friendly for patients.

METHODS

A total of 1170 participants were surveyed using a structured online questionnaire to assess the perceptions towards the adoption of telemedicine in healthcare delivery services. Multivariate analysis was performed to identify key variables of knowledge and attitude affecting the utilization of telemedicine.

RESULTS

Of the total respondents, 35.3% of patients never encountered telemedicine before and 26.9% did not come across telemedicine even during the COVID-19 pandemic.

CONCLUSION

Understanding the perceptions of patients, using targeted health education, positive communication, and behavioral modifications, is the key factor to be addressed to mitigate the apprehensions towards telemedicine and improve the utilization of the services.

COVID-19 Remote Consultation Services and Population in Health Inequity-Concentrating Territories: A Scoping Review

Background: This review aimed to map initiatives for measuring the satisfaction of vulnerable populations with teleconsultation services offered by public and private health care providers in their territories, during the coronavirus disease (COVID-19) pandemic. Systematic studies on the opinions of people most affected by health inequities are limited. Therefore, we included evaluations of teleconsultation-based services offered to socioeconomically disadvantaged and clinically vulnerable populations globally, with a focus on surveillance, treatment, and prevention of COVID-19.

Materials and Methods: This review includes analytical and descriptive observational studies primarily from MEDLINE, EMBASE, SCOPUS, and Web of Science databases, published after the World Health Organization received the first warnings about COVID-19 from Chinese authorities in December, 2019, until December 2020. The search strategy combined aspects of COVID-19, telemedicine, patient satisfaction, and key concepts of vulnerable populations.

Results: We selected 33 studies for full-text reading and 10 for critical appraisal. Two categories emerged from the qualitative analysis: telehealth evaluation and services during COVID-19, and opinions of vulnerable populations. Television and social networks play a crucial role in providing information. Although teleconsultations are practical and cost effective for patients, the majority preferred receiving in-person treatment in primary care clinics.

Conclusions: Listening to the opinions of vulnerable groups and their caregivers is critical both before and during adoption of COVID-19 control measures. Health managers need to monitor the health of and delivery of services to socioeconomically and clinically vulnerable people closely, to improve services, and provide care from a human rights perspective.

Telemedicine Applications for the Evaluation of Patients with Non-Acute Headache: A Narrative Review

The COVID-19 pandemic has spurred a hasty transition to virtual care but also an abundance of new literature highlighting telehealth’s capabilities and limitations for various healthcare applications. In this review, we aim to narrate the current state of the literature on telehealth applied to migraine care. First, telemedicine in the context of non-acute headache management has been shown to produce non-inferior patient outcomes when compared to traditional face-to-face appointments. The assignment of patients to telehealth appointments should be made after referring more urgent cases to dedicated in-person clinics. During the virtual appointment, physicians can ask their patients about the “3 F’s” in order to perform a thorough assessment of their headaches: frequency of headache days, frequency of acute medication usage and functional impairment. Clinical assessment scores that have been studied and deemed feasible for telemedicine, safe and efficient include the HIT-6, VAS and MIDAS scores. Although MIDAS was found to be redundant and inadequate to use on a daily basis, we suggest that it can be useful in periodic remote follow-up appointments. Additionally, several mobile health apps have been studied including Migraine Buddy, Migraine Coach and Migraine Monitor. All of these are appropriate for use in telemedicine when combined with an adequate trial period with Migraine Buddy being rated the highest, as it captures the most detailed clinical picture. High satisfaction rates have been reported for virtual headache management which were shown to be equal to in-person consults. These are based on patients’ perceived increase in convenience due to avoided travel time, less disruption of their daily routine and feeling more comfortable in the environment of their choice. Despite this, limitations such as technological knowledge, access to videoconferencing modalities and having a more impersonal consultation with the physician may hinder some patients from adopting this service.

Telemedicine versus Physical Examination in Patients’ Assessment during COVID-19 Pandemic: The Dubai Experience

Introduction

With the large number of cases during the COVID-19 pandemic, a smart tool was urgently needed to handle all the positive cases at proper time such as using the technology and implementing telemedicine for triage.

Objective

The purpose of this study is to detect the accuracy and effectiveness of telemedicine as an assessment tool for triage compared to physical assessment.

Methods

In a random sample of 1,086 COVID-19 positive cases during the pandemic in Dubai, all the patients were initially assessed by trained staff using telemedicine following a standardized guidelines and accordingly action was taken by sending the patient to an isolation facility or for hospital admission; the second phase of assessment was conducted physically at the facility. We compared the accuracy of assessment by telemedicine encounter versus physical assessment by detecting any changes of the initial action within 12 h.

Results

Telemedicine was accurate in 1,080 out of 1,086 screened patients (99.4%).

Discussion

Telemedicine offers fast and convenient response to patients needs with standardization of triage guidelines. Telemedicine has reduced exposure of the medical workers which reduced the possibility of infection as well as reduction of crowds at the medical centers.

Recommendations

Telemedicine is very useful during the COVID-19 pandemic for following up the positive and suspected cases as well as cases with history of close contact with a confirmed positive case.