Patient Use, Experience, and Satisfaction With Telehealth in an Australian Population (Reimagining Health Care): Web-Based Survey Study

BACKGROUND

The COVID-19 pandemic triggered a rapid scale-up of telehealth services in Australia as a means to provide continued care through periods of physical restrictions. The factors that influence engagement in telehealth remain unclear.

OBJECTIVE

The purpose of this study is to understand the experience of Australian people who engaged in a telehealth consultation during the pandemic period (2020-2021) and the demographic factors that influence engagement.

METHODS

A web-based survey was distributed to Australians aged over 18 years that included 4 questions on frequency and type of clinical consultation, including with a general practitioner (GP), specialist, allied health, or nurse; 1 question on the experience of telehealth; and 2 questions on the quality of and satisfaction with telehealth. Statistical analysis included proportion of responses (of positive responses where a Likert scale was used) and regression analyses to determine the effect of demographic variables.

RESULTS

Of the 1820 participants who completed the survey, 88.3% (1607/1820) had engaged in a health care consultation of some type in the previous 12 months, and 69.3% (1114/1607) of those had used telehealth. The most common type of consultation was with a GP (959/1114, 86.1%). Older people were more likely to have had a health care consultation but less likely to have had a telehealth consultation. There was no difference in use of telehealth between metropolitan and nonmetropolitan regions; however, people with a bachelor's degree or above were more likely to have used telehealth and to report a positive experience. A total of 87% (977/1114) of participants agreed or strongly agreed that they had received the information they required from their consultation, 71% (797/1114) agreed or strongly agreed that the outcome of their consultation was the same as it would have been face-to-face, 84% (931/1114) agreed or strongly agreed that the doctor or health care provider made them feel comfortable, 83% (924/1114) agreed or strongly agreed that the doctor or health care provider was equally as knowledgeable as providers they have seen in person; 57% (629/1114) of respondents reported that they would not have been able to access their health consultation if it were not for telehealth; 69% (765/1114) of respondents reported that they were satisfied with their telehealth consultation, and 60% (671/1114) reported that they would choose to continue to use telehealth in the future.

CONCLUSIONS

There was a relatively high level of engagement with telehealth over the 12 months leading up to the study period, and the majority of participants reported a positive experience and satisfaction with their telehealth consultation. While there was no indication that remoteness influenced telehealth usage, there remains work to be done to improve access to older people and those with less than a bachelor's degree.

Consumer preferences for telehealth in Australia: A discrete choice experiment

This study aims to elicit consumer preferences regarding telehealth and face-to-face consultations in Australia. It used a discrete choice experiment, presenting participants with a series of hypothetical choices, and based on their responses, infer what is most important to them. Data were analysed using conditional logit regression and latent class analysis. A total of 1,025 participants completed the survey, considering four different clinical scenarios. Face-to-face contacts were, on average, preferred to either telephone or video services. However, telehealth was identified as an attractive option if it prevents significant travel and can be conducted with a familiar doctor. Participants were strongly driven by cost, particularly greater than $30. Telehealth was least preferred for situations involving a new and unknown physical symptom, and relatively more preferred for surgical follow-up. The latent class analysis demonstrates only 15.9% of participants appeared unwilling to consider telehealth. The findings of this study suggest that meeting the needs of the Australian population requires a blended approach to service delivery, with telehealth being valued in a range of clinical scenarios. Price sensitivity was evident, therefore if telehealth services can be delivered with lower patient cost, then they are likely to be attractive.

Consumer preferences, experiences, and attitudes towards telehealth: Qualitative evidence from Australia

In Australia, telehealth is not new, with several telehealth specialist services being available for those living in rural and remote communities. However, prior to the COVID-19 pandemic, telehealth was not routinely available for primary care or urban specialist appointments. There has been an increased focus in the use of telehealth within primary care, and particularly general practice, but overall, there has been limited research to date to guide telehealth best-practice based on consumer experiences and preferences within these settings. We aimed to capture the consumer experience of telehealth during the COVID-19 pandemic, through a novel Kitchen Table Discussion (KTD) method. This increases access to a broader community consumer cohort, with consumer hosts leading discussions in a safe environment. The KTDs were conducted in May 2021, with 10 community members each hosting a group of up to 10 participants. A total of 90 participants took part from across Australia, with the majority living in major cities, although a significant proportion lived in inner and outer regional areas of Australia, or had experience living in rural, regional or remote areas. Seventy percent of participants reported using telehealth in the past. Data were analysed sequentially using thematic analysis and identified key themes: modality, convenience, access, wait time, existing relationship, communication, connectivity, cost, and privacy. Overall, the future of telehealth looks hopeful from the perspective of the consumer, but significant improvements are required to improve consumer engagement and experience. It is evident that ‘one size does not fit all’, with results suggesting consumers value the availability of telehealth and having choice and flexibility to use telehealth when appropriate, but do not want to see telehealth replacing face-to-face delivery. Participants tended to agree that telehealth was not a preferred method when physical examination was required but would suit certain points of the patient journey.

Educational attainment and willingness to use technology for health and to share health information - The reimagining healthcare survey

BACKGROUND

Australia has seen a rapid uptake of virtual care since the start of the COVID-19 pandemic. We aimed to describe the willingness of consumers to use digital technology for health and to share their health information; and explore differences by educational attainment and area of remoteness.

METHODS

We conducted an online survey on consumer preferences for virtual modes of healthcare delivery between June and September 2021. Participants were recruited through the study's partner organisations and an online market research company. Australian residents aged ≥18 years who provided study consent and completed the survey were included in the analysis. We reported the weighted percentages of participants who selected negative response to the questions to understand the size of the population that were unlikely to adopt virtual care. Age-adjusted Poisson regression models were used to estimate the prevalence ratios for selecting negative response associated with education and remoteness.

RESULTS

Of the 1778 participants included, 29% were not aware of digital technologies for monitoring/supporting health, 22% did not have access to technologies to support their health, and 19% were not willing to use technologies for health. Over a fifth of participants (range: 21-34%) were not at all willing to use seven of the 15 proposed alternative methods of care. Between 21% and 36% of participants were not at all willing to share de-identified health information tracked in apps/devices with various not-for-profit organisations compared to 47% with private/for-profit health businesses. Higher proportions of participants selected negative response to the questions in the lower educational attainment groups than those with bachelor's degree or above. No difference was observed between area of remoteness.

CONCLUSIONS

Improving the digital health literacy of people, especially those with lower educational attainment, will be required for virtual care to become an equitable part of normal healthcare delivery in Australia.

A three-step strategy of induction chemotherapy then chemoradiation followed by surgery in patients with potentially resectable carcinoma of the esophagus or gastroesophageal junction

BACKGROUND

Patients with locoregional carcinoma of the esophagus or gastroesophageal junction have a poor survival rate after surgery. Preoperative chemotherapy or chemoradiotherapy has not improved the outcome for these patients. Our study was designed to assess the feasibility of preoperative induction combination chemotherapy in addition to chemoradiotherapy to improve the curative resection rate, local control, and survival. PATIENTS AND METHODS Patients having histologic proof of localized carcinoma (either squamous cell carcinoma or adenocarcinoma) of the esophagus or gastroesophageal junction underwent full classification including endoscopic ultrasonography (EUS). Patients first received up to two courses of induction chemotherapy consisting of 5-fluorouracil at 750 mg/m(2)/day as continuous infusion on Days 1--5, cisplatin at 15 mg/m(2)/day as an intravenous bolus on Days 1--5, and paclitaxel at 200 mg/m(2) as a 24-hour intravenous infusion on Day 1. The second course was repeated on Day 29. This was followed by radiotherapy (45 grays in 25 fractions) and concurrent admission of 5-fluorouracil (300 mg/m(2)/day as a continuous infusion 5 days/week) and cisplatin (20 mg/m(2) on Days 1--5 of radiotherapy). After chemoradiotherapy, patients underwent surgery. The feasibility of this approach, curative resection rates, patient survival, and patterns of failure were assessed.

RESULTS

Thirty-seven of 38 patients enrolled were evaluable for toxicity and survival. Adenocarcinoma and distal esophageal location of carcinoma were observed frequently. Thirty-five (95%) of the 37 patients underwent surgery, all of whom had an R0 (curative) resection. A pathologic complete response was noted in 11 (30%) of the 37 total patients. In addition, 5 patients (14%) had only microscopic carcinoma. According to EUS classification, 31 (89%) of the 35 patients who underwent surgery had a T3 carcinoma whereas according to pathologic classification only 3 (9%) had a T3 carcinoma (P </= 0.01). Similarly, according to EUS classification, 23 patients (66%) had an N1 carcinoma, whereas according to pathologic classification only 7 patients (20%) had an N1 carcinoma (P < or = 0.01). At a median follow-up of 20 months (minimum follow-up, 13+ months; maximum follow-up, 36+ months), the median survival duration for the 37 patients had not yet been reached. In addition, there were two deaths related to surgery.

CONCLUSIONS

These data show that the three-step strategy of preoperative paclitaxel-based induction chemotherapy then chemoradiotherapy followed by surgery is feasible and appears quite active in patients having locoregional carcinoma of the esophagus or gastroesophageal junction. Future investigations should focus on substituting cisplatin with less toxic agents and including more systemic therapy with newer classes of agents.

A three-step strategy of induction chemotherapy then chemoradiation followed by surgery in patients with potentially resectable carcinoma of the esophagus or gastroesophageal junction

BACKGROUND

Patients with locoregional carcinoma of the esophagus or gastroesophageal junction have a poor survival rate after surgery. Preoperative chemotherapy or chemoradiotherapy has not improved the outcome for these patients. Our study was designed to assess the feasibility of preoperative induction combination chemotherapy in addition to chemoradiotherapy to improve the curative resection rate, local control, and survival. PATIENTS AND METHODS Patients having histologic proof of localized carcinoma (either squamous cell carcinoma or adenocarcinoma) of the esophagus or gastroesophageal junction underwent full classification including endoscopic ultrasonography (EUS). Patients first received up to two courses of induction chemotherapy consisting of 5-fluorouracil at 750 mg/m(2)/day as continuous infusion on Days 1--5, cisplatin at 15 mg/m(2)/day as an intravenous bolus on Days 1--5, and paclitaxel at 200 mg/m(2) as a 24-hour intravenous infusion on Day 1. The second course was repeated on Day 29. This was followed by radiotherapy (45 grays in 25 fractions) and concurrent admission of 5-fluorouracil (300 mg/m(2)/day as a continuous infusion 5 days/week) and cisplatin (20 mg/m(2) on Days 1--5 of radiotherapy). After chemoradiotherapy, patients underwent surgery. The feasibility of this approach, curative resection rates, patient survival, and patterns of failure were assessed.

RESULTS

Thirty-seven of 38 patients enrolled were evaluable for toxicity and survival. Adenocarcinoma and distal esophageal location of carcinoma were observed frequently. Thirty-five (95%) of the 37 patients underwent surgery, all of whom had an R0 (curative) resection. A pathologic complete response was noted in 11 (30%) of the 37 total patients. In addition, 5 patients (14%) had only microscopic carcinoma. According to EUS classification, 31 (89%) of the 35 patients who underwent surgery had a T3 carcinoma whereas according to pathologic classification only 3 (9%) had a T3 carcinoma (P </= 0.01). Similarly, according to EUS classification, 23 patients (66%) had an N1 carcinoma, whereas according to pathologic classification only 7 patients (20%) had an N1 carcinoma (P < or = 0.01). At a median follow-up of 20 months (minimum follow-up, 13+ months; maximum follow-up, 36+ months), the median survival duration for the 37 patients had not yet been reached. In addition, there were two deaths related to surgery.

CONCLUSIONS

These data show that the three-step strategy of preoperative paclitaxel-based induction chemotherapy then chemoradiotherapy followed by surgery is feasible and appears quite active in patients having locoregional carcinoma of the esophagus or gastroesophageal junction. Future investigations should focus on substituting cisplatin with less toxic agents and including more systemic therapy with newer classes of agents.

Zanamivir use during transmission of amantadine-resistant influenza A in a nursing home

OBJECTIVE

To describe the use of zanamivir during an influenza A outbreak.

POPULATION

Residents of a 176-bed long-term-care facility for the elderly in Newmarket, Ontario, Canada, 90% of whom received influenza vaccine in the fall of 1998.

OUTBREAK

When respiratory illness due to influenza A was confirmed, infection control measures and amantadine prophylaxis were initiated. Despite these measures, transmission of influenza A continued.

INTERVENTION

Zanamivir inhalations, 10 mg daily for prophylaxis and 10 mg twice daily for treatment of influenza.

RESULTS

There were 13 definite and 66 probable outbreak-associated cases of influenza A. Twelve (15%) cases developed pneumonia, 7 (9%) were hospitalized, and 2 (2.6%) died. All 12 culture-positive cases yielded influenza A/Sydney/H3N2/05/97-like virus, a 1998/99 vaccine component. The three isolates obtained prior to the initiation of amantadine were amantadine-susceptible; all nine obtained after prophylaxis was instituted were amantadine-resistant. One hundred twenty-nine (92%) of 140 residents who were offered zanamivir accepted it and were able to attempt inhalations. Of these 129, 78% (100) had no difficulty in complying with inhalations. Difficulty with inhalations was associated with decreased functional and mental status. Fifteen (58%) of 26 residents fully dependent in activities of daily living had difficulty compared to 14 (14%) of 100 others (P<.001). Twenty-two (45%) of 49 residents not oriented to person, place, or time had difficulty compared to 7 (10%) of 77 others (P<.001). In the 2 weeks after zanamivir prophylaxis, only 2 new cases of respiratory illness occurred, neither confirmed as influenza. No side effects were identified in 128 zanamivir-treated residents.

CONCLUSION

A minority of nursing home residents have difficulty following instructions for zanamivir inhalations. Zanamivir was well tolerated, and its use was temporally associated with termination of an outbreak that amantadine had failed to control.

Preparation of nuclear extracts from myelinating Schwann cells

Myelination of peripheral nerve fibres is performed by Schwann cells and is associated with the coordinate upregulation of lipid synthesis and multiple genes encoding myelin-specific proteins. Both the decision to enter into a myelinating phenotype and subsequently, the quantity of myelin that each Schwann cell elaborates appear to be controlled by axonal signals. Understanding of the relevant signaling pathways and the downstream transcription factors and cis elements that confer myelin gene expression is notably limited. In large part, this has resulted directly from a lack of methods for obtaining nuclear extracts from myelinating Schwann cells thus precluding the application of numerous powerful molecular techniques. In this report, we describe a method that overcomes this limitation for the myelinating Schwann cells in the sciatic nerves of the mouse. During the evolution of the method, its effectiveness was monitored using an oligonucleotide containing the binding site for KROX-20, a transcription factor known to be present in myelinating Schwann cells. Following technical development, the optimized protocol has proven to be entirely reliable and thus novel experimental strategies now can be applied to the investigation of the molecular mechanisms controlling gene expression in peripheral nerves.

A multidisciplinary approach to therapy for unresectable malignant thymoma

BACKGROUND

The therapeutic outcome for unresectable, locally advanced, malignant thymoma has been poor.

OBJECTIVE

To improve tumor resectability and patient survival rates by studying a multimodal approach to therapy for unresectable malignant thymoma.

DESIGN

Prospective cohort study.

SETTING

Tertiary care cancer center.

PARTICIPANTS

All eligible patients had newly diagnosed, histologically proven, unresectable malignant thymoma.

INTERVENTION

The treatment regimen consisted of induction chemotherapy (three courses of cyclophosphamide, doxorubicin, cisplatin, and prednisone), surgical resection, postoperative radiation therapy, and consolidation chemotherapy (three courses of cyclophosphamide, doxorubicin, cisplatin, and prednisone). Tissue samples were taken at the time of surgical resection for assessment of tumor necrosis and Ki-67 expression.

MEASUREMENTS

Tumor response and resectability (both overall and after induction chemotherapy) and disease-free survival rate in patients who received multimodal therapy.

RESULTS

13 patients were consecutively enrolled from February 1990 to December 1996, and 12 evaluable patients were assessed for response. Disease responded to induction chemotherapy completely in 3 patients (25%) and partially in 8 patients (67%); 1 patient had a minor response (8%). Eleven patients had surgical resection; 1 refused surgery. Tumors were removed completely in 9 (82%) and incompletely in 2 (18%) of 11 patients who had been receiving radiation therapy and consolidation chemotherapy. All 12 patients are alive (100% at 7 years), with a median follow-up of 43 months, and 10 patients are disease free (73% disease-free survival at 7 years). A high correlation was seen between tumor necrosis after induction chemotherapy and Ki-67 expression (r=-0.88).

CONCLUSIONS

Aggressive multimodal treatment is highly effective and may cure locally advanced, unresectable malignant thymoma.

Patients with limited-stage small-cell lung cancer treated with concurrent twice-daily chest radiotherapy and etoposide/cisplatin followed by cyclophosphamide, doxorubicin, and vincristine

PURPOSE

A phase II trial in patients with limited-stage small-cell lung cancer treated with induction etoposide/cisplatin plus twice-daily chest radiotherapy was conducted in an attempt to increase response rates and prolong survival.

PATIENTS AND METHODS

Fifty-four previously untreated patients with limited-stage small-cell cancer were treated with etoposide/cisplatin and concurrent radiotherapy at 1.5 Gy twice daily for 3 weeks to a total dose of 45 Gy. Patients then received three more cycles of etoposide/cisplatin followed by four cycles of vincristine, doxorubicin, and cyclophosphamide or an individualized chemotherapy regimen.

RESULTS

Nine patients are alive and free of cancer a median of 4 years (range, 2 to 7) from the start of treatment. Thirty-eight have had progression of their cancer at a median of 1.2 years (range, 0.5 to 5.4) and all have died of small-cell cancer. Thirteen of these 38 patients' (34%) only site of initial relapse was in the CNS and all died of CNS metastases. Five patients died during therapy or from its complications and two patients died of causes other than relapsed small-cell lung cancer and toxicity. The median survival time is 21.3 months, with an actual survival rate of 83% at 1 year, and actuarial survival rates of 43% at 2 years and 19% at 5 years.

CONCLUSION

This combined modality regimen for patients with limited-stage small-cell lung cancer results in a 2-year survival rate of 43%, but the principal cause of death in these patients is still relapse of the original cancer. Isolated CNS metastases caused more than 30% of the cancer deaths.

Stability of ursodiol in an extemporaneously compounded oral liquid

The stability of ursodiol in an extemporaneous oral liquid formulation refrigerated at 4 degrees C for 35 days was studied. A suspension was prepared by opening commercially available 300-mg capsules of ursodiol, adding Glycerin, USP, to form a paste, and then adding Simple Syrup, NF. A control solution was prepared from analytical-grade ursodiol powder in simple syrup. The final concentration of ursodiol in both formulations was 60 mg/mL. Three samples of each preparation were stored in 2-oz, amber glass prescription bottles in the dark at 4 degrees C. Immediately after preparation and at 7, 14, 21, 28, and 35 days, samples were visually inspected, tested for pH, and assayed in duplicate by high-performance liquid chromatography. Stability was defined as the retention of more than 90% of the initial concentration. On day 35, the mean percentage of the initial ursodiol concentration remaining was 96.5% in the suspension made from powder-filled capsules, and 100.6% in the suspension made from analytical-grade powder. The color, odor, and pH of the samples did not change appreciably over the study period. An extemporaneously compounded oral liquid preparation of ursodiol in simple syrup was stable under the conditions studied for up to 35 days.

The vasopressin response to severe birth asphyxia

Serial measurements of urinary arginine vasopressin (AVP) were made in six severely birth asphyxiated newborn infants. In five infants serial plasma concentrations were also evaluated. There was a strong negative correlation between plasma AVP and plasma osmolality in these infants (r = -0.52, P = 0.0012). In neither the individual babies nor the group as a whole was there a significant correlation between plasma AVP and the urinary excretion of AVP even if the latter was standardised for creatinine content. Normal development at follow up was only observed in two asphyxiated infants who had consistently low urinary arginine vasopressin levels in the first days of life. Infants with consistently high urinary vasopressin concentrations either died or were severely abnormal in their subsequent development.

Coumarin necrosis of the penis

Coumarin-induced necrosis of the skin and subcutaneous tissue is an uncommon but well recognized complication of anticoagulant therapy. Although any area of skin may be involved necrosis of the penis is rare. We report a case of penile necrosis associated with coumarin therapy and review the literature.