An In-Person and Telemedicine "Hybrid" System to Improve Cross-Border Critical Care in COVID-19.
Ontology highlight
ABSTRACT: Background
UC San Diego Health System (UCSDHS) is an academic medical center and integrated care network in the US-Mexico border area of California contiguous to the Mexican Northern Baja region. The COVID-19 pandemic deeply influenced UCSDHS activities as new public health challenges increasingly related to high population density, cross-border traffic, economic disparities, and interconnectedness between cross-border communities, which accelerated development of clinical collaborations between UCSDHS and several border community hospitals - one in the US, two in Mexico - as high volumes of severely ill patients overwhelmed hospitals.Objective
We describe the development, implementation, feasibility, and acceptance of a novel critical care support program in three community hospitals along the US-Mexico border.Methods
We created and instituted a hybrid critical care program involving: 1) in-person activities to perform needs assessments of equipment and supplies and hands-on training and education, and 2) creation of a telemedicine-based (Tele-ICU) service for direct patient management and/or consultative, education-based experiences. We collected performance metrics surrounding adherence to evidence-based practices and staff perceptions of critical care delivery.Findings
In-person intervention phase identified and filled gaps in equipment and supplies, and Tele-ICU program promoted adherence to evidence-based practices and improved staff confidence in caring for critically ill COVID-19 patients at each hospital.Conclusion
A collaborative, hybrid critical care program across academic and community centers is feasible and effective to address cross-cultural public health emergencies.
SUBMITTER: Ramnath VR
PROVIDER: S-EPMC7792461 | biostudies-literature | 2021 Jan
REPOSITORIES: biostudies-literature
Publications
An In-Person and Telemedicine "Hybrid" System to Improve Cross-Border Critical Care in COVID-19.
Ramnath Venktesh R VR Hill Linda L Schultz Jim J Mandel Jess J Smith Andres A Morris Tim T Holberg Stacy S Horton Lucy E LE Malhotra Atul A Friedman Lawrence S LS
Annals of global health 20210104 1
<h4>Background</h4>UC San Diego Health System (UCSDHS) is an academic medical center and integrated care network in the US-Mexico border area of California contiguous to the Mexican Northern Baja region. The COVID-19 pandemic deeply influenced UCSDHS activities as new public health challenges increasingly related to high population density, cross-border traffic, economic disparities, and interconnectedness between cross-border communities, which accelerated development of clinical collaborations ...[more]
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Project description:BackgroundUC San Diego Health System (UCSDHS) is the largest academic medical center and integrated care network in US-Mexico border area of California contiguous to the Northern Baja region of Mexico. The COVID-19 pandemic compelled several UCSDHS and local communities to create awareness around best methods to promote regional health in this economically, socially, and politically important border area.PurposeTo improve understanding of optimal strategies to execute critical care collaborative programs between academic and community health centers facing public health emergencies during the COVID-19 pandemic, based on the experience of UCSDHS and several community hospitals (one US, two Mexican) in the US-Mexico border region.MethodsAfter taking several preparatory steps, we developed a two-phase program that included 1) in-person activities to perform needs assessments, hands-on training and education, and morale building and 2) creation of a telemedicine-based (Tele-ICU) service for direct patient management and/or educational coaching experiences.Findings.A clinical and educational program between academic and community border hospitals was feasible, effective, and well received.ConclusionWe offer several policy-oriented recommendations steps for academic and community healthcare programs to build educational, collaborative partnerships to address COVID-19 and other cross-cultural, international public health emergencies.
| S-EPMC8356755 | biostudies-literature
Project description:BackgroundKidney transplant recipients are immunocompromised and require lifelong follow-up. Recipients face geographic, socioeconomic, and logistical challenges when seeking follow-up that can be alleviated using telemedicine. We aimed to understand patient experiences and preferences regarding telemedicine video visits and highlight insights to advance adopting hybrid telemedicine/in-person transplant care.MethodsWe conducted qualitative in-depth, semi-structured interviews with kidney transplant recipients between November 18, 2022, and January 11, 2023. Participants had follow-up at ≥12 months post-transplant via telemedicine at a tertiary transplant center. Study enrollment continued until data saturation was reached (n = 20 participants) when no new information emerged from additional interviews. Transcripts were analyzed using inductive thematic analysis.ResultsParticipants median age was 58 years (IQR, 52-72), and 50% were female, 45% were White, 30% were Black, 15% were Asian, 10% were Hispanic/Other persons, and 30% were out-of-state residents. We identified the following seven themes: (1) reducing travel time, (2) minimizing financial burden (decreasing travel-related expenses and lost wages), (3) engaging patients within their comfort space, (4) establishing rapport with patients, (5) limitations of the virtual physical exam, (6) enhancing access to transplant providers (maximizing adherence to follow-up), and (7) lowering risk of communicable diseases.ConclusionsIntegrating telemedicine with in-person visits enhances post-transplant follow-up care. A hybrid model should leverage the strengths of both modalities, ensuring patient access to care and being patient-centered and flexible. Efforts are needed to advance technological tools in physical examination and human connection, and assess patient outcomes. Policymakers and healthcare systems need to incentivize the adoption and expansion of telemedicine in transplant care.
| S-EPMC11822748 | biostudies-literature
Project description:ImportanceTelemedicine is an increasingly used yet understudied vehicle to deliver pediatric primary care. Evidence detailing downstream health care utilization after telemedicine visits is needed.ObjectiveTo compare pediatric primary care conducted via telemedicine (video or telephone) with in-person office visits with regard to physician medication prescribing and imaging and laboratory ordering and downstream follow-up office visits, emergency department (ED) visits, and hospitalizations.Design, setting, and participantsThis cohort study included all patients younger than 18 years who had scheduled primary care appointments with a pediatrician from January 1 to December 31, 2022, in the Kaiser Permanente Northern California health system, a large integrated health care delivery system offering in-person office visits, video visits, or telephone visits for pediatric primary care.ExposurePediatric primary care in-person visit, telephone visit, or video visit.Main outcome and measuresRates of physician medication prescribing and imaging and laboratory ordering during an index telemedicine or office visit and rates of in-person office visits, ED visits, and hospitalizations within 7 days after the visit, adjusted for patient and clinical characteristics.ResultsOf 782 596 total appointments (51.1% male) among 438 638 patients, telemedicine was used for 332 153 visits (42.4%). After adjustment, there was more medication prescribing for in-person visits (39.8%) compared with video visits (29.5%; adjusted difference, -10.3%; 95% CI, -10.6% to -10.0%) or telephone visits (27.3%; adjusted difference, -12.5%; 95% CI, -12.5% to -12.7%). There was also more laboratory ordering for in-person visits (24.6%) compared with video visits (7.8%; adjusted difference, -16.8%; 95% CI, -17.0% to -16.6%) or telephone visits (8.5%; adjusted difference, -16.2%; 95% CI, -16.3% to -16.0%). There was more imaging ordering for in-person visits (8.5%) compared with video visits (4.0%; adjusted difference, -4.5%; 95% CI, -4.6% to -4.4%) and telephone visits (3.5%; adjusted difference, -5.0%; 95% CI, -5.1% to -4.9%). After adjustment, fewer in-person follow up visits occurred for index visits that were in-person (4.3%) compared with video (14.4%; adjusted difference, 10.1%; 95% CI, 9.9%-10.3%) or telephone (15.1%; adjusted difference, 10.8%; 95% CI, 10.7%-11.0%) visits. The rate of ED visits following an in-person visit was slightly lower (1.75%) compared with after video visits (2.04%; adjusted difference, 0.29%; 95% CI, 0.21%-0.38%) or telephone visits (2.00%; adjusted difference, 0.25%; 95% CI, 0.18%-0.33%). There was no statistically significant difference in the 7-day rate of hospitalizations.Conclusions and relevanceIn this cohort study, telephone and video visits for pediatric primary care were associated with less prescribing and ordering than in-person visits. Telemedicine visits were associated with modestly higher rates of subsequent in-person visits and slightly higher rates of ED visits, and there was no difference in hospitalizations. Telemedicine appears to be a useful vehicle for health care delivery in the pediatric population, although it is not a universal substitute for in-person visits.
| S-EPMC11584922 | biostudies-literature
Project description:ImportanceThe hybrid ophthalmology telemedicine model asynchronously pairs an imaging appointment by a technician with a subsequent virtual appointment by a clinician. Although it has been mentioned in several studies as an alternative to standard in-person care during the COVID-19 pandemic, outcomes of this alternative clinical care model remain to be evaluated.ObjectiveTo investigate the outcomes associated with the hybrid ophthalmology telemedicine model during the COVID-19 pandemic for nonurgent and nonprocedural ophthalmological care.Design, setting, and participantsRetrospective, cross-sectional study of all hybrid visits scheduled during the year 2020 in a single academic, hospital-based eye clinic in Boston, Massachusetts. All hybrid ophthalmology telemedicine visits completed in the year 2020 by opthalmologists and optometrists were included. Data were analyzed from January to December 2020.ExposuresHybrid telemedicine clinical encounters.Main outcomes and measuresFour outcome metrics were calculated: (1) need for subsequent procedure visit, (2) medication change, (3) nonurgent, and (4) urgent consultation with another eye clinician. Adverse outcomes were defined as irreversible vision loss and the need for additional in-person evaluation to reach a management decision.ResultsFrom April 9 to December 30, 2020, 889 patients (506 female patients [56.9%]; mean [SD] age, 62.1 [14.5] years; age range, 13-98 years) completed 940 hybrid visits. The most common visit indications were glaucoma (424 visits [45.1%]) and retinal diseases (499 visits [53.1%]). A total of 25 visits (2.7%) led to a procedure, 22 visits (2.3%) led to a change in medication, and 44 visits (4.7%) were referred for nonurgent consultation with another subspecialty with no instances of urgent referrals. Sixteen patients (1.7%) were referred to the on-call clinician for a same-day emergency in-person visit or recommended for a subsequent standard in-person visit to reach a management decision. There were no cases of irreversible vision loss following a hybrid visit.Conclusions and relevanceThese findings suggest that with the appropriate patient selection and clinical setting, the hybrid ophthalmology telemedicine model may be a good alternative to standard in-person visits, particularly for patients with glaucoma and retinal diseases.
| S-EPMC9412225 | biostudies-literature
Project description:BackgroundBeyond initial COVID-19 pandemic emergency expansions of telemedicine use, it is unclear how well primary care telemedicine addresses patients' needs.ObjectiveTo compare treatment and follow-up visits (office, emergency department, hospitalization) between primary care video or telephone telemedicine and in-person office visits.DesignRetrospective design based on administrative and electronic health record (EHR) data.SettingLarge, integrated health care delivery system with more than 1300 primary care providers, between April 2021 and December 2021 (including the COVID-19 pandemic Delta wave).Patients1 589 014 adult patients; 26.5% were aged 65 years or older, 54.9% were female, 22.2% were Asian, 7.4% were Black, 22.3% were Hispanic, 46.5% were White, 21.5% lived in neighborhoods with lower socioeconomic status, and 31.8% had a chronic health condition.MeasurementsTreatment outcomes included medication or antibiotic prescribing and laboratory or imaging ordering. Follow-up visits included in-person visits to the primary care office or emergency department or hospitalization within 7 days. Outcomes were adjusted for sociodemographic and clinical characteristics overall and stratified by clinical area (abdominal pain, gastrointestinal concerns, back pain, dermatologic concerns, musculoskeletal pain, routine care, hypertension or diabetes, and mental health).ResultsOf 2 357 598 primary care visits, 50.8% used telemedicine (19.5% video and 31.3% telephone). After adjustment, medications were prescribed in 46.8% of office visits, 38.4% of video visits, and 34.6% of telephone visits. After the visit, 1.3% of in-person visits, 6.2% of video visits, and 7.6% of telephone visits had a 7-day return in-person primary care visit; 1.6% of in-person visits, 1.8% of video visits, and 2.1% of telephone visits were followed by an emergency department visit. Differences in follow-up office visits were largest after index office versus telephone visits for acute pain conditions and smallest for mental health.LimitationsIn the study setting, telemedicine is fully integrated with ongoing EHRs and with clinicians, and the study examines an insured population during the late COVID-19 pandemic period. Observational comparison lacks detailed severity or symptom measures. Follow-up was limited to 7 days. Clinical area categorization uses diagnosis code rather than symptom.ConclusionIn-person return visits were somewhat higher after telemedicine compared with in-person primary care visits but varied by specific clinical condition.Primary funding sourceAgency for Healthcare Research and Quality.
| S-EPMC11382601 | biostudies-literature
Project description:ImportanceTelemedicine visits can offer patients convenient access to a clinician, but it is unclear whether treatment differs from that with in-person visits or how often patients require in-person follow-up.ObjectiveTo examine whether physician prescribing and orders differ between telemedicine and office visits, whether physicians conducting telemedicine visits are more likely to require in-person follow-up, and whether telemedicine visits are associated with more health events.Design, setting, and participantsThis cohort study included all patients who scheduled primary care appointments through the patient portal of a large integrated health care delivery system newly implementing patient-scheduled video telemedicine visits from January 2016 to May 2018.Main outcomes and measuresAdjusted rates of any medication prescribed or laboratory tests or imaging ordered and rates of follow-up health care utilization (in-person visits, emergency department visits, and hospitalizations) within 7 days after the index visit, stratified by index primary care visit type, were generated using multivariable adjustment for patient, access, and clinical characteristics.ResultsThis study included 1 131 722 patients (611 821 [54%] female; mean [SD] age, 43 [22] years) with 2 178 440 total appointments (307 888 [14%] telemedicine), of which 13.5% were for patients younger than 18 years, 22.2% were for patients 65 years or older, and 54.9% were for female patients. After adjustment, 38.6% (95% CI, 38.0%-39.3%) of video visits, 34.7% (95% CI, 34.5%-34.9%) of telephone visits, and 51.9% (95% CI, 51.8%-52.0%) of office visits had any medication prescribed; laboratory tests or imaging were ordered for 29.2% (95% CI, 28.5%-29.8%) of video visits, 27.3% (95% CI, 27.1%-27.5%) of telephone visits, and 59.3% (95% CI, 59.3%-59.4%) of clinic visits. After adjustment, follow-up visits within 7 days occurred after 25.4% (95% CI, 24.7%-26.0%) of video visits, 26.0% (95% CI, 25.9%-26.2%) of telephone visits, and 24.5% (95% CI, 24.5%-24.6%) of office visits. Adjusted emergency department visits and rates of hospitalizations were not statistically significantly different by primary care index visit type.Conclusions and relevanceIn this cohort study of patient self-scheduled primary care telemedicine visits within ongoing patient-physician relationships, prescribing and orders were significantly lower for telemedicine visits than for clinic visits, with slightly higher follow-up office visits for telemedicine but no difference in health events (emergency department visits or hospitalizations). Video or telephone visits may be a convenient and efficient way to access primary care and address patient needs.
| S-EPMC8596201 | biostudies-literature
Project description:ImportanceDespite its rapid adoption during the COVID-19 pandemic, it is unknown how telemedicine augmentation of in-person office visits has affected quality of patient care.ObjectiveTo examine whether quality of care among patients exposed to telemedicine differs from patients with only in-person office-based care.Design, setting, and participantsIn this retrospective cohort study, standardized quality measures were compared between patients with office-only (in-person) visits vs telemedicine visits from March 1, 2020, to November 30, 2021, across more than 200 outpatient care sites in Pennsylvania and Maryland.ExposuresPatients completing telemedicine (video) visits.Main outcomes and measuresχ2 tests determined statistically significant differences in Health Care Effectiveness Data and Information Set (HEDIS) quality performance measures between office-only and telemedicine-exposed groups. Multivariable logistic regression controlled for sociodemographic factors and comorbidities.ResultsThe study included 526 874 patients (409 732 office-only; 117 142 telemedicine exposed) with a comparable distribution of sex (196 285 [49.7%] and 74 878 [63.9%] women), predominance of non-Hispanic (348 127 [85.0%] and 105 408 [90.0%]) and White individuals (334 215 [81.6%] and 100 586 [85.9%]), aged 18 to 65 years (239 938 [58.6%] and 91 100 [77.8%]), with low overall health risk scores (373 176 [91.1%] and 100 076 [85.4%]) and commercial (227 259 [55.5%] and 81 552 [69.6%]) or Medicare or Medicaid (176 671 [43.1%] and 52 513 [44.8%]) insurance. For medication-based measures, patients with office-only visits had better performance, but only 3 of 5 measures had significant differences: patients with cardiovascular disease (CVD) receiving antiplatelets (absolute percentage difference [APD], 6.71%; 95% CI, 5.45%-7.98%; P < .001), patients with CVD receiving statins (APD, 1.79%; 95% CI, 0.88%-2.71%; P = .001), and avoiding antibiotics for patients with upper respiratory infections (APD, 2.05%; 95% CI, 1.17%-2.96%; P < .001); there were insignificant differences for patients with heart failure receiving β-blockers and those with diabetes receiving statins. For all 4 testing-based measures, patients with telemedicine exposure had significantly better performance differences: patients with CVD with lipid panels (APD, 7.04%; 95% CI, 5.95%-8.10%; P < .001), patients with diabetes with hemoglobin A1c testing (APD, 5.14%; 95% CI, 4.25%-6.01%; P < .001), patients with diabetes with nephropathy testing (APD, 9.28%; 95% CI, 8.22%-10.32%; P < .001), and blood pressure control (APD, 3.55%; 95% CI, 3.25%-3.85%; P < .001); this was also true for all 7 counseling-based measures: cervical cancer screening (APD, 12.33%; 95% CI, 11.80%-12.85%; P < .001), breast cancer screening (APD, 16.90%; 95% CI, 16.07%-17.71%; P < .001), colon cancer screening (APD, 8.20%; 95% CI, 7.65%-8.75%; P < .001), tobacco counseling and intervention (APD, 12.67%; 95% CI, 11.84%-13.50%; P < .001), influenza vaccination (APD, 9.76%; 95% CI, 9.47%-10.05%; P < .001), pneumococcal vaccination (APD, 5.41%; 95% CI, 4.85%-6.00%; P < .001), and depression screening (APD, 4.85%; 95% CI, 4.66%-5.04%; P < .001).Conclusions and relevanceIn this cohort study of patients with telemedicine exposure, there was a largely favorable association with quality of primary care. This supports telemedicine's value potential for augmenting care capacity, especially in chronic disease management and preventive care. This study also identifies a need for understanding relationships between the optimal blend of telemedicine and in-office care.
| S-EPMC9513647 | biostudies-literature
Project description:BackgroundThe coronavirus disease (COVID-19) pandemic has disrupted medical education for trainees of all levels. Although telesimulation was initially used to train in resource-limited environments, it may be a reasonable alternative for replicating authentic patient experiences for medical students during the COVID-19 pandemic. It is unclear whether a more passive approach through telesimulation training is as effective as traditional in-person simulation training.ObjectiveOur aim was to evaluate the effectiveness of in-person versus remote simulation training on learners' comfort with managing critical care scenarios.MethodsThis was a prospective observational cohort study assessing the impact of an in-person versus remote simulation course on volunteer fourth-year medical students from February to April 2021 at the University of California San Diego School of Medicine. Precourse and postcourse surveys were performed anonymously using an online secure resource.ResultsIn the in-person learners, there was statistically significant improvement in learner comfort across all technical, behavioral, and cognitive domains. In remote learners, there was a trend toward improvement in self-reported comfort across technical and cognitive domains in the telesimulation course. However, the only statistically significant improvement in postcourse surveys of telesimulation learners, compared with baseline, was in running codes. Regardless of the training modality, the students had a positive experience with the critical care simulation course, ranking it, on average, 9.6 out of 10 (9.9 in in-person simulation vs. 9.3 in telesimulation; P = 0.06).ConclusionWe demonstrated that implementation of a telesimulation-based simulation course focusing on critical care cases is feasible and well received by trainees. Although a telesimulation-based simulation course may not be as effective for remote learners as active in-person participants, our study provided evidence that there was still a trend toward improving provider readiness across technical and cognitive domains when approaching critical care cases.
| S-EPMC8787731 | biostudies-literature
Project description:The coronavirus disease 2019 (COVID-19) crisis has amplified the importance of palliative care to countless patients suffering with and dying from this disease, as well as to their families, communities, and the worldwide cadre of overburdened health care workers. Particularly urgent is the need for spiritual care specialists and generalists to address spiritual suffering given the degree of isolation, loneliness, and vulnerability caused by this pandemic. Although spiritual care has long been recognized as one of the domains of quality palliative care, it is often not fully integrated into practice. All disciplines are ultimately responsible for ensuring that spiritual care is prioritized to improve quality of life and the experience of patients and families facing spiritual emergencies amid the complex life-and-death scenarios inherent to coronavirus disease 2019. Although the pandemic has revealed serious fault lines in many health care domains, it has also underscored the need to recommit to spiritual care as an essential component of whole-person palliative care.
| S-EPMC7332903 | biostudies-literature
Project description:ObjectivesTelemedicine critical care is associated with improved efficiency, quality, and cost-effectiveness. As of 2010, fewer than 5% of U.S. hospitals had telemedicine critical care, and fewer than 10% of ICU beds were covered. We evaluated recent telemedicine critical care implementation and bed coverage rates in the United States and compared characteristics of hospitals with and without telemedicine critical care.DesignCross-sectional study of 2018 American Hospital Association Annual Survey Database.SettingU.S. hospitals.PatientsNone.InterventionsNone.Measurements and main resultsWe obtained data regarding telemedicine critical care implementation, ICU capability (defined as ≥ 1 ICU bed), other hospital characteristics, and the Herfindahl-Hirschman Index, a measure of ICU market competition based on hospital referral regions. Among 4,396 hospitals (response rate 71%), 788 (17.9%) had telemedicine critical care, providing potential coverage to 27,624 (28% of total) ICU beds. Among 306 hospital referral regions, 197 (64%) had a respondent hospital with telemedicine critical care. Telemedicine critical care implementation was associated with being a nonprofit (odds ratio, 7.75; 95% CI, 5.18-11.58) or public (odds ratio, 4.16 [2.57-6.73]) compared with for-profit hospital; membership in a health system (odds ratio, 3.83 [2.89-5.08]; stroke telemedicine presence (odds ratio, 6.87 [5.35-8.81]); ICU capability (odds ratio, 1.68 [1.25-2.26]); and more competitive ICU markets (odds ratio per 1,000-point decrease in Herfindahl-Hirschman Index 1.11 [1.01-1.22]). Notably, rural critical access hospitals had lower odds of telemedicine critical care implementation (odds ratio, 0.49 [0.34-0.70]). Teaching status, geographic region, and rurality were not associated with telemedicine critical care implementation.ConclusionsAbout one fifth of respondent hospitals had telemedicine critical care by 2018, providing potential coverage of nearly one third of reported ICU beds. This represents a substantial increase in telemedicine critical care implementation over the last decade. Future expansion to include more rural hospitals that could benefit most may be aided by addressing hospital financial and market barriers to telemedicine critical care implementation.
| S-EPMC8245115 | biostudies-literature