High‐Intensity Telemedicine‐Enhanced Acute Care for Older Adults: An Innovative Healthcare Delivery Model

Accessing timely acute medical care is a challenge for older adults. This article describes an innovative healthcare model that uses high‐intensity telemedicine services to provide rapid acute care for older adults without requiring them to leave their senior living community (SLC) residences. This program, based in a primary care geriatrics practice that cares for SLC residents, is designed to offer acute care through telemedicine for complaints that are felt to need attention before the next available outpatient visit but not to require emergency department (ED) resources. This option gives residents access to care in their residence. Measures used to evaluate the program include successful completion of telemedicine visits, satisfaction of residents and caregivers with telemedicine care, and site of care that would have been recommended had telemedicine been unavailable. During the first 2 years of the program's operation, 281 of 301 requested telemedicine visits were completed successfully. Twelve residents were sent to an ED for care after the telemedicine visit. Ninety‐four percent of residents reported being satisfied or very satisfied with telemedicine care. Had telemedicine not been available, residents would have been sent to an ED (48.1%) or urgent care center (27.0%) or been scheduled for an outpatient visit (24.4%). The project demonstrated that high‐intensity telemedicine services for acute illnesses are feasible and acceptable and can provide definitive care without requiring ED or urgent care use. Continuation of the program will require evaluation demonstrating equal or better resident‐level outcomes and the development of sustainable business models.     

The impact of telemedicine on patient self-management processes and clinical outcomes for patients with Types I or II Diabetes Mellitus in the United States: A scoping review

ObjectiveThe objective of this scoping review was to identify peer-reviewed medical literature on the use of telemedicine in patients with Types I or II DM in the United States, assess its impact on self-management processes and clinical outcomes of care, and to delineate research gaps.MethodsWe utilized a structured scoping review protocol to conduct this research. We searched the published medical literature utilizing two databases, PubMed and CINHAL, and we included all original research articles published prior to July 20th, 2018. Using a 4-step systematic approach, we identified, reviewed, extracted and summarized data from all relevant studies.ResultsWe identified 47 articles overall. Telemedicine impact was reported as positive in articles addressing the following components of patient self-management: adherence to blood glucose monitoring, day-to-day decision-making related to self-care, and adherence with medications. The most commonly reported clinical outcome was HbA1c level. Few or no studies evaluated impact on long term clinical outcomes such as blindness, amputation, cardiovascular events, development of chronic kidney disease, or mortality.DiscussionThis scoping review provides important information about studies conducted in the United States evaluating the impact of telemedicine on patient self-management and on clinical outcomes in patients with DM.ConclusionsResults suggest that telemedicine has a positive impact on self-management processes and on HbA1c levels. However, future evaluative reviews are necessary to confirm and quantitate the impact of telemedicine on self-management processes and primary studies are necessary to evaluate its impact on long term clinical outcomes.     

Patients’ Perspectives on the Shift to Telemedicine in Primary and Behavioral Health Care during the COVID-19 Pandemic

BackgroundStudies specifically focused on patients’ perspectives on telemedicine visits in primary and behavioral health care are fairly limited and have often focused on highly selected populations or used overall satisfaction surveys.ObjectiveTo examine patient perspectives on the shift to telemedicine, the remote delivery of health care via the use of electronic information and communications technology, in primary and behavioral health care in Federally Qualified Health Centers (FQHCs) during COVID-19.DesignSemi-structured interviews were conducted using video conference with patients and caregivers between October and December 2020.ParticipantsProviders from 6 FQHCs nominated participants. Eighteen patients and caregivers were interviewed: 6 patients with only primary care visits; 5 with only behavioral health visits; 3 with both primary care and behavioral health visits; and 4 caregivers of children with pediatric visits.ApproachUsing a protocol-driven, rapid qualitative methodology, we analyzed the interview data and assessed the quality of care, benefits and challenges of telemedicine, and use of telemedicine post-pandemic.Key ResultsRespondents broadly supported the option of home-based synchronous telemedicine visits in primary and behavioral health care. Nearly all respondents appreciated remote visits, largely because such visits provided a safe option during the pandemic. Patients were generally satisfied with telemedicine and believed the quality of visits to be similar to in-person visits, especially when delivered by a provider with whom they had established rapport. Although most respondents planned to return to mostly in-person visits when considered safe to do so, they remained supportive of the continued option for remote visits as remote care addresses some of the typical barriers faced by low-income patients.ConclusionsAddressing digital literacy challenges, enhancing remote visit privacy, and improving practice workflows will help ensure equitable access to all patients as we move to a new post-COVID-19 “normal” marked by increased reliance on telemedicine and technology.KEY WORDS: telemedicine, COVID-19, primary care, behavioral health, qualitative     

Top 50 cited articles on Covid-19 after the first year of the pandemic: A bibliometric analysis

Background & aimsIt has been just over a year since the Covid-19 pandemic started. The top 50 cited articles on this subject would help identify trends and focus on the research efforts.MethodsWe utilised e-utilities in PubMed to find publications on Covid-19 until the date of search on 7/2/21. The iCite website was used to find the top 50 citations of the output from the search strategy. We looked into their full text for the editorial dates, type of study, level of evidence, focus of the article and country of origin. We also counted the errata and comments on each of them.ResultsThe total number of citations of all 50 articles was 123,960, the highest being 10, 754 for a single article. Huang C was the most cited first author. They were published from week 4–17, with February being the month with most citations. Lancet was the most cited journal, having published 9 of the 50 articles. Majority belonged to level 3 of the evidence ladder and were retrospective studies. Thirty percent of them had an errata published and an average of 7 comments per article.ConclusionThe top 50 most cited articles identify the most impactful studies on Covid-19, providing a resource to educators while identifying trends to guide research and publishing efforts. There has been an explosion of publications and an unprecedented rate and number of citations within the first year for any single condition in the literature.     

Evaluation of cognition in cancer patients: special focus on the elderly

PURPOSE: The risks of both cognitive dysfunction and most cancers increase with age. A literature review was undertaken to identify how cognitive issues in older patients were being assessed in the oncology literature. METHODS: A systematic literature search was undertaken using a number of different search terms and databases to find all relevant articles in oncology and internal medicine journals. RESULTS: Eighty-eight articles were included in the review. Just over half of the articles studied a mixture of cancer types and had fewer than 100 patients. The vast majority of patients being studied were <65 years of age. While a little over half of the articles used >or=3 neuropsychological tests to assess cognition, more than 60 different tests were used to assess cognition. Forty-one percent of the studies were prospective trials, with most of the rest divided between cross-sectional and observational. One-fifth of the articles involved patients at end-of-life. CONCLUSION: The oncology literature contains little information about cognition in older cancer patients. More systematic and comprehensive studies of this important aspect of cancer care in the elderly are necessary.     

Adherence of published diabetes mellitus practice guidelines to methodologic standards of guideline development.

There are multiple practice guidelines published pertaining to diabetes care. Experts have formulated methodologic standards of guideline formulation. To determine whether practice guidelines pertaining to diabetes and published in peer-reviewed publications and the Internet adhered to established methodologic standards of guideline development. We identified all guidelines pertaining to diabetes care published between 1980 and 2000 using a computerized search of Medline, the Practice Guidelines Clearinghouse, the Institute for Clinical Systems Improvement Web site, and a global internet search engine. We used a previously validated 25-item assessment tool to determine guideline adherence to methodologic standards in three categories: guideline development and format, identification and summary of evidence, and formulation of recommendations. We conducted a multivariable regression analysis to determine the influence of guideline author, publishing medium, year of publication, and guidelines length on adherence to methodologic standards of guideline development. We evaluated 43 guidelines: 33% published on the Internet, 66% in peer-reviewed journals; 51% published by organizations, and 49% by individual experts. Of a maximum of 25 methodologic standards, the number of standards adhered by a guideline was 9 (range, 2 to 19). Mean proportion (SD) of guidelines that adhered to methodologic standards on guideline development and format was 48% (28); on identification and summary of evidence, 21% (22); and on the formulation of recommendations, 36% (27). Longer guidelines had greater adherence to methodologic standards (P < 0.0001). Guidelines pertaining to diabetes care published on the internet and in peer-reviewed publications do not meet most methodologic standards of guideline development.     

Disparities in Telemedicine Use for Subspecialty Diabetes Care During COVID-19 Shelter-In-Place Orders

Background:During the COVID-19 pandemic, telemedicine use rapidly and dramatically increased for management of diabetes mellitus. It is unknown whether access to telemedicine care has been equitable during this time. This study aimed to identify patient-level factors associated with adoption of telemedicine for subspecialty diabetes care during the pandemic.Methods:We conducted an explanatory sequential mixed-methods study using data from a single academic medical center. We used multivariate logistic regression to explore associations between telemedicine use and demographic factors for patients receiving subspecialty diabetes care between March 19 and June 30, 2020. We then surveyed a sample of patients who received in-person care to understand why these patients did not use telemedicine.Results:Among 1292 patients who received subspecialty diabetes care during the study period, those over age 65 were less likely to use telemedicine (OR: 0.34, 95% CI: 0.22-0.52, P < .001), as were patients with a primary language other than English (OR: 0.53, 95% CI: 0.31-0.91, P = .02), and patients with public insurance (OR: 0.64, 95% CI: 0.49-0.84, P = .001). Perceived quality of care and technological barriers were the most common reasons cited for choosing in-person care during the pandemic.Conclusions:Our findings suggest that, amidst the COVID-19 pandemic, there have been disparities in telemedicine use by age, language, and insurance for patients with diabetes mellitus. We anticipate telemedicine will continue to be an important care modality for chronic conditions in the years ahead. Significant work must therefore be done to ensure that telemedicine services do not introduce or widen population health disparities.     

Evaluation of cognition in cancer patients: Special focus on the elderly

PurposeThe risks of both cognitive dysfunction and most cancers increase with age. A literature review was undertaken to identify how cognitive issues in older patients were being assessed in the oncology literature.MethodsA systematic literature search was undertaken using a number of different search terms and databases to find all relevant articles in oncology and internal medicine journals.ResultsEighty-eight articles were included in the review. Just over half of the articles studied a mixture of cancer types and had fewer than 100 patients. The vast majority of patients being studied were <65 years of age. While a little over half of the articles used ≥3 neuropsychological tests to assess cognition, more than 60 different tests were used to assess cognition. Forty-one percent of the studies were prospective trials, with most of the rest divided between cross-sectional and observational. One-fifth of the articles involved patients at end-of-life.ConclusionThe oncology literature contains little information about cognition in older cancer patients. More systematic and comprehensive studies of this important aspect of cancer care in the elderly are necessary.     

The Need for Telemedicine Integration Into Adult Cardiology Training Curricula in Canada

COVID-19 brought telemedicine to the forefront of clinical cardiology. We aimed to examine the extent of trainees’ involvement in and comfort with telemedicine practices in Canada with the use of a web-based self-administered survey. Eighty-six trainees from 12 training programs completed the survey (65% response rate). Results showed that before COVID-19, 39 trainees (45%) had telemedicine exposure, compared with 67 (78%) after COVID-19 (P < 0.001). However, only 44 trainees (51%) reported being comfortable or very comfortable with the use of telemedicine. Of the 67 trainees who were involved in telemedicine, 4 (6%) had full supervision during virtual visits, 13 (19%) had partial supervision, and 50 (75%) had minimal or no supervision. Importantly, 67 trainees (78%) expressed the need for telemedicine-specific training and 64 (74%) were willing to have their virtual visits recorded for the purpose of evaluation and feedback. Furthermore, 47 (55%) felt strongly or very strongly positive about incorporating telemedicine into their future practice. The main perceived barriers to telemedicine use were concerns about patients’ engagement, fear of weakening the patient-physician relationship, and unfamiliarity with telemedicine technology. These barriers, together with training in virtual physical examination skills and medicolegal aspects of telemedicine, are addressed in several established internal medicine telemedicine curricula that could be adapted by cardiology programs. In conclusion, while the degree of telemedicine involvement since COVID-19 was high, the trainees’ comfort level with telemedicine practice remains suboptimal likely due to lack of training and inadequate staff supervision. Therefore, a cardiology telemedicine curriculum is needed to ensure that trainees are equipped to embrace telemedicine in cardiovascular clinical care.     

How to find evidence when you need it,part 4: Matching clinical questions to appropriate databases

Practitioners seeking enhancement of clinical care through consideration of research require rapid and efficient point-of-care access to current studies and summaries pertaining to specific clinical queries. MEDLINE and other large databases usually contain the citations relevant to such questions but frequently fall short of the practical requirements of busy clinicians. We present a summary of the knowledge and skills required for physicians to select and use smaller databases appropriate to particular types of questions arising from emergency care. We outline a step-by-step approach that begins at the bedside with the sorting of questions into appropriate categories of knowledge and research design. We identify commonly encountered pitfalls in the process of connecting a particular question to an appropriate database. We illustrate the approach through a set of demonstration questions pertaining to patients presenting to emergency departments with chest pain consistent with acute coronary ischemia. We describe a selection of resources and databases and summarize their performance in locating articles relevant to the demonstration questions.     

Systematic review of emergency department crowding: causes, effects, and solutions

Emergency department (ED) crowding represents an international crisis that may affect the quality and access of health care. We conducted a comprehensive PubMed search to identify articles that (1) studied causes, effects, or solutions of ED crowding; (2) described data collection and analysis methodology; (3) occurred in a general ED setting; and (4) focused on everyday crowding. Two independent reviewers identified the relevant articles by consensus. We applied a 5-level quality assessment tool to grade the methodology of each study. From 4,271 abstracts and 188 full-text articles, the reviewers identified 93 articles meeting the inclusion criteria. A total of 33 articles studied causes, 27 articles studied effects, and 40 articles studied solutions of ED crowding. Commonly studied causes of crowding included nonurgent visits, "frequent-flyer" patients, influenza season, inadequate staffing, inpatient boarding, and hospital bed shortages. Commonly studied effects of crowding included patient mortality, transport delays, treatment delays, ambulance diversion, patient elopement, and financial effect. Commonly studied solutions of crowding included additional personnel, observation units, hospital bed access, nonurgent referrals, ambulance diversion, destination control, crowding measures, and queuing theory. The results illustrated the complex, multifaceted characteristics of the ED crowding problem. Additional high-quality studies may provide valuable contributions toward better understanding and alleviating the daily crisis. This structured overview of the literature may help to identify future directions for the crowding research agenda.     

Perceptions of patients with chronic obstructive pulmonary disease towards telemedicine: A qualitative systematic review

BackgroundThere are some qualitative studies on the views of patients with chronic obstructive pulmonary disease (COPD) on telemedicine, however, there are few related qualitative systematic reviews.ObjectivesTo systematically review and synthesize qualitative studies involving the perceptions of patients with COPD about telemedicine to understand patients' attitudes and expectations for telemedicine and determine the obstacles and stimulus in the use of telemedicine.MethodsWe searched PubMed, Web of Science, MEDLINE, Embase and CINAHL for articles published from January 2000 to December 2020. The data were analysed using thematic synthesis.ResultsWe included 20 articles involving 19 studies and 301 patients, and we identified four themes: perceived ease of use, perceived usefulness, perceived difficulty of use, and perceived uselessness. We found that although patients have different views on telemedicine, most of them have a positive attitude towards it.ConclusionsThe synthesis of views will help us determine the factors that promote or hinder the application of telemedicine and guide the design and implementation of telemedicine in the future.     

COVID-19 and applications of smartphone technology in the current pandemic

BackgroundWith restrictions on face to face clinical consultations in the COVID-19 pandemic and the challenges faced by health care systems in delivering patient care, alternative information technologies like telemedicine and smartphone are playing a key role.AimsWe assess the role and applications of smartphone technology as an extension of telemedicine in provide continuity of care to our patients and surveillance during the current COVID-19 pandemic.MethodsWe have done a comprehensive review of the literature using suitable keywords on the search engines of PubMed, SCOPUS, Google Scholar and Research Gate in the first week of May 2020.ResultsThrough the published literature on this topic, we discuss role, common applications and its support in extended role of telemedicine technology in several aspects of current COVID-19 pandemic.ConclusionSmartphone technology on its own and as extension of telemedicine has significant applications in the current COVID-19 pandemic. As the smartphone technology further evolves with fifth generation cellular network expansion, it is going to play a key role in future of health medicine, patient referral, consultation, ergonomics and many other extended applications of health care.     

An analysis of the emergency medicine literature: 1982 through 1985

This study analyzed the subject matter and type of articles published by the three peer-reviewed journals of emergency medicine from 1982 through 1985. Subject matter was classified by the author according to the Emergency Medicine Core Content. Articles were classified by type (research, case reports, reviews, editorials, etc). The data were cross-tabulated to determine how each of the subject areas was covered. The analysis included 1,573 contributions to the three journals over the four-year period. Results are reported for each journal. The small proportion of articles published on administration and education were mostly anecdotal information and only 14% to 15% were based on objective studies. A very small proportion of articles in general emergency medicine, 2% to 4%, were based on basic research. More than one-half of the basic research published in two of the three journals related to resuscitation. Two-thirds of the articles pertaining to toxicology were anecdotal. Articles pertaining to emergency medical services and trauma achieved a balanced distribution of type of articles. Major subject areas not covered over the four-year period are also reported and discussed.     

Delivering Urgent Care Using Telemedicine: Insights from Experienced Clinicians at Academic Medical Centers

BackgroundCare delivered using telemedicine has been steadily growing in the USA but represented a small fraction of overall visits before the COVID-19 pandemic as few clinicians had been providing care using telemedicine. Understanding how experienced clinicians have practiced telemedicine can help guide today’s exponential adoption of telemedicine.ObjectiveThe objective of this study was to explore barriers and facilitators to providing effective, high-quality urgent care using telemedicine (“tele-urgent care”) from the perspective of clinicians experienced in telemedicine.ApproachWe conducted semi-structured interviews between July 2018 and March 2019 of clinicians who had been providing tele-urgent care services to patients as a part of their routine clinical practice. Themes were identified using content analysis with a constant comparative coding approach.Key ResultsAmong the 20 clinicians interviewed, the majority were female (90%) and nurse practitioners (65%). We identified four themes related to barriers and facilitators to providing effective, high-quality tele-urgent care. Workplace factors such as a strong information technology (IT) infrastructure, real-time IT support, an electronic health record, and a collegial work environment, often virtual, were necessary standards. Communication and exam techniques from in-person encounters were adapted to tele-urgent care including active listening skills and teaching patients to conduct specific exam maneuvers virtually. The convenience of tele-urgent care should be preserved to support improvements in access to care. Finally, patients and clinicians occasionally had mismatched expectations about what could or would be provided during a tele-urgent care encounter. Managing the added tension that can occur during a telemedicine encounter was important.ConclusionAs telemedicine becomes an integral part of the care continuum, incorporating and accounting for these key insights when we train and support clinicians will be necessary to provide effective, high-quality care to patients in the future.KEY WORDS: telemedicine, provider experiences, urgent care     

Gastroenterologist specialist care and care provided by generalists--an evaluation of effectiveness and efficiency

OBJECTIVE: In this era of cost containment, gastroenterologists must demonstrate that they provide effective and efficient care. The aim of this study was to evaluate the process and outcomes of care provided by gastroenterologists and generalist physicians (internists, family physicians, general surgeons) for GI conditions. METHODS: We conducted a systematic literature review using a MEDLINE search of English language articles (January 1980 to September 1998). A total of 2157 articles were identified; 10 met inclusion criteria for systematic review. In addition, there were nine articles that described the results of physician surveys, and examined the process of care among gastroenterologists and generalist physicians. RESULTS: Care provided by gastroenterologists for GI bleeding and diverticulitis resulted in significantly shorter length of hospital stay. Gastroenterologists diagnosed celiac disease more accurately than generalists, and more adequately diagnosed colorectal cancer and prescribed antimicrobials for peptic ulcer disease. There was no difference between gastroenterologists and generalists in terms of colonoscopy procedure time, and family physicians detected a greater number of cancers. Furthermore, there was no difference in the outcomes of gastroesophageal reflux disease therapy in patients seen by gastroenterologists, versus those educated by nurses. The survey articles suggested that gastroenterologists were more likely to test and treat for Helicobacter pylori in patients with peptic ulcer disease, and were more likely recommended for medical versus surgical therapy. Gastroenterologists had a lower threshold for ordering ERCP before cholecystectomy than surgeons, but had similar responses regarding indications for surgery in inflammatory bowel disease. Finally, primary care physicians were less likely to associate symptoms of profuse watery diarrhea with cryptosporidium infection compared with gastroenterologists and infectious disease specialists. CONCLUSIONS: We reached the following conclusions: 1) The results suggest that gastroenterologists deliver effective and efficient care for GI bleeding and diverticulitis and provide more effective diagnosis in certain disorders. 2) Studies are limited by retrospective design, small sample size, and lack of control groups. 3) To fully evaluate care by gastroenterologists, prospective comparisons with greater attention to methodology are needed.     

The hidden burden of influenza: A review of the extra‐pulmonary complications of influenza infection

Severe influenza infection represents a leading cause of global morbidity and mortality. Although influenza is primarily considered a viral infection that results in pathology limited to the respiratory system, clinical reports suggest that influenza infection is frequently associated with a number of clinical syndromes that involve organ systems outside the respiratory tract. A comprehensive MEDLINE literature review of articles pertaining to extra‐pulmonary complications of influenza infection, using organ‐specific search terms, yielded 218 articles including case reports, epidemiologic investigations, and autopsy studies that were reviewed to determine the clinical involvement of other organs. The most frequently described clinical entities were viral myocarditis and viral encephalitis. Recognition of these extra‐pulmonary complications is critical to determining the true burden of influenza infection and initiating organ‐specific supportive care.     

Survey of HIV care providers on management of HIV serodiscordant couples – assessment of attitudes,knowledge, and practices

Human immunodeficiency virus (HIV) serodiscordant couples are at risk of sexual transmission of HIV between the infected and uninfected partner. We assessed New York area care providers for people living with HIV regarding attitudes, knowledge, and practice patterns toward fertility and conception in serodiscordant couples. Data were collected via a survey distributed in October 2013. Seventeen percent of respondents reported prescribing antiretroviral preexposure prophylaxis (PrEP) for a woman in a serodiscordant couple, and 38% percent of respondents reported having counseled serodiscordant couples on timed, unprotected intercourse without PrEP. Respondents who reported being “very” familiar with the data on HIV transmission in serodiscordant couples were more likely to report counseling their patients in timed, unprotected intercourse compared with those who reported less familiarity with the data (41% vs. 8%, p = 0.001). Although only 20% reported being “very” or “somewhat” familiar with the data on the safety of sperm washing with intrauterine insemination, those who did were more likely to have reported referring a patient for assisted reproductive technology (61% vs. 32%, p = 0.006). Effective patient counseling and referral for appropriate reproductive options were associated with knowledge of the literature pertaining to these options. This emphasizes the need for further provider education on reproductive options and appropriate counseling for serodiscordant couples.