Primary Care Providers'' Perceptions of Home Diabetes Telemedicine Care in the IDEATel Project

CONTEXT: Few telemedicine projects have systematically examined provider satisfaction and attitudes. PURPOSE: To determine the acceptability and perceived impact on primary care providers' (PCP) practices of a randomized clinical trial of the use of telemedicine to electronically deliver health care services to Medicare patients with diabetes in federally designated medically underserved areas of upstate New York, primarily those in rural areas and small towns with limited access to primary care. METHODS: A longitudinal phone survey was completed by 116 PCPs with patients with diabetes in the treatment arm of the trial, and conducted 12 and 24 months after a PCP's first patient was randomized to the home telemedicine arm of the trial. The 36-item survey included measures of acceptability (to PCPs, time required), impact (on patient knowledge, confidence, perceived health outcomes), and communication. Six open-ended questions were analyzed qualitatively. RESULTS: The quantitative data indicated positive responses in terms of acceptability of the telemedicine intervention to the PCPs and of the impact on the PCPs' patients. This was most evident in issues critical to good control of diabetes: patient knowledge, ability to manage diabetes, confidence, and compliance in managing diabetes. Key qualitative themes, on the positive end, were more patient control and motivation, helpfulness of having extra patient data, and involvement of nurses and dieticians. Negative themes were excessive paperwork and duplication taking more PCP time, and conflicting advice and management decisions from the telemedicine team, some without informing the PCP but none involving medications. CONCLUSIONS: Telemedicine was reported to be a positive experience for predominantly rural PCPs and their Medicare-eligible patients from medically underserved areas; several inefficiencies need to be refined.     

Differences in readiness between rural hospitals and primary care providers for telemedicine adoption and implementation: findings from a statewide telemedicine survey

Purpose: Published advantages of and challenges with telemedicine led us to examine the scope of telemedicine adoption, implementation readiness, and barriers in a southern state where adoption has been historically low. We hypothesized that rural hospitals and primary care providers (RPCPs) differ on adoption, readiness, and implementation barriers. We examined the degree to which they differ on (a) telemedicine adoption or readiness; (b) telemedicine training needs; (c) current use of technology for patient care; and (d) environmental concerns in facilities for telemedicine. Methods: Paper surveys were sent to rural hospitals and RPCPs with response rates of 50% (n = 38) and 25.9% (n = 339), respectively. Three of 4 hospitals were represented. Chi‐square analyses were used to test for differences between rural hospitals and RPCPs. Findings: Compared to RPCPs, rural hospitals were significantly more likely to report higher rates of telemedicine knowledge (P= .0007); planning for or implementing telemedicine (P < .0001); and reporting their disaster recovery data systems (P= .0002) and availability and location of outlets and connections (P= .03) as adequate for telemedicine. Rural hospitals were less likely to report having no telemedicine education needs (P= .04). Conclusions: Telemedicine continues to be a viable solution for bridging geographic access gaps to a variety of specialty care. Users need assistance in understanding legal implications, care coordination, billing for services, and disaster data recovery. In rural areas, hospitals appear to best embody characteristics of facilities that successfully implement telemedicine and have the greatest degree of readiness.     

农村高血压和糖尿病患者对健康管理服务的认知与评价研究:以扬州市江都区为例

目的:分析农村高血压和糖尿病患者对健康管理服务的认知与评价,发现问题并提出对策。方法:采用分层随机抽样方法调查农村高血压和糖尿病患者570人,应用描述性统计和logistic回归分析患者对健康管理服务的认知与评价。结果:绝大部分农村慢性病患者知晓健康管理服务,对疾病控制效果的满意率达82.28%,其中年龄低于60岁患者的满意率偏低(P0.05),为77.24%,患者认为健康管理服务内容提供不足的方面主要有上门随访、健康体检和并发症防治(选择比例分别为11.90%、10.41%和9.29%);农村健康管理服务的问题主要有随访次数少、医疗设备不全和服务项目开展不足(选择比例分别为16.36%、9.29%和8.92%)。结论:构建乡村两级医疗卫生机构的协作机制,加大农村公共卫生的投入,加强农村卫生人员培训,合理安排上门随访、健康讲座等,提高高血压和糖尿病等慢性病的管理质量与效果。     

Telemedicine in the emergency department: a randomized controlled trial.

Emergency physicians and nurses were trained in telemedicine techniques in two emergency departments, one rural (low volume) and one suburban (high volume). Fifteen patient complaints were selected as appropriate for the study. Of 122 patients who met the inclusion criteria, 104 (85%) consented to participate. They were randomized to control and experimental groups. The suburban emergency physician diagnosed and treated the control patients. Experimental patients presenting to the high-volume emergency department were evaluated and treated by the telemedicine nurse in person and the rural emergency physician via the telemedicine link. Immediately before discharge all telemedicine patients were re-evaluated by the suburban emergency physician. Data collected on each patient included: diagnosis; treatment; 72 h return visits; need for additional care; and satisfaction of patient, physicians and nurses. There were no significant differences (P > 0.05) for occurrence of 72 h return visits, need for additional care or overall patient satisfaction. The average patient throughput time (from admission to discharge) was 106 min for the telemedicine group and 117 min for the control group. Telemedicine was a satisfactory technique for the chosen group of patients in the emergency department and was acceptable to the participants.     

An evaluation of satisfaction with telemedicine among health-care professionals

A survey was conducted among non-doctor health-care professionals in six rural counties in Missouri. The purpose of the survey was to establish baseline data to evaluate the effect of changes in the health-care sector, especially technology changes, on the job satisfaction, career satisfaction, relationships and communication activities of health professionals. The survey included three rural counties in which integrated telecommunication and interactive video telemedicine services were being installed, but before significant activities had begun, and three comparator counties without substantial integrated telecommunications infrastructure and telemedicine services. During a one-month study period, 1108 questionnaires were distributed. The total response rate was 50.1% (n = 555). Of the respondents, 30.3% indicated that technology in health-care was having a large effect on their work, although only 18.2% indicated that telemedicine and telecommunications were having a large effect. No systematic differences were found among the health professionals in the two communities at the time telemedicine equipment was being installed.     

Perspectives from the Veterans Health Administration about opportunities and barriers in telemedicine

We used qualitative interviews to examine the perceptions of direct providers of telemedicine services, primary care providers (PCPs) and hospital administrators about opportunities and barriers to the implementation of telemedicine services in a network of Veterans Health Administration hospitals. A total of 37 interviews were conducted (response rate of 28%) with 17 direct telemedicine providers, nine PCPs and 11 administrators. The overall inter-coder reliability across all themes was high (Scott's pi = 0.94). Direct telemedicine providers generally agreed that telemedicine improved rapport with patients, and respondents in all three groups generally agreed that telemedicine improves access, productivity, and the quality and coordination of care. Respondents mentioned several benefits to home telemedicine, including the ability to better manage chronic diseases, provide frequent clinician contact, facilitate quick responses to patient needs and provide care in patient's homes. Most respondents anticipated future growth in telemedicine services. Barriers to telemedicine implementation included technical challenges, the need for more education and training for patients and staff, preferences for in-person care, the need for programme improvement and the need for additional staff time to provide telemedicine services.     

Patient satisfaction with teledermatology: quantitative and qualitative results from a randomized controlled trial

As part of a randomized controlled trial involving 208 dermatology patients, a quantitative and qualitative study was undertaken to explore patients' satisfaction with a specialist dermatological opinion and further management obtained through either a traditional outpatient consultation (control group) or an asynchronous teleconsultation (telemedicine group). There was a response rate of 71% to the quantitative patient satisfaction survey (148 replies from 208 distributed questionnaires). The responders comprised 80 of the 111 telemedicine patients (72%) and 68 of the 97 control patients (70%). Overall levels of patient satisfaction were high in both groups, and there was no significant difference between them. Ninety per cent of patients in the control group were satisfied with their overall care, compared with 81% in the telemedicine group, and 87% of patients in the control group were satisfied with their overall management, compared with 84% in the telemedicine group. Follow-up qualitative interviews with 30 of the participants also suggested that patients were generally positive about their care and management, regardless of group, age or gender. Receiving a diagnosis, treatment and cure, receiving adequate information and explanations, the need to be taken seriously, the need for individualized personal care, and the importance of a short waiting time for an appointment and treatment were all aspects of care and management most likely to result in patient satisfaction, regardless of modality.     

Patient satisfaction with telemedical access to specialty services in rural California

We assessed patient satisfaction with the use of telemedicine in rural California, in comparison with usual face-to-face care. A standardized patient satisfaction questionnaire was developed using a five-point scale to measure dimensions of care in a telemedicine environment. Twenty-four primary care sites in 18 Californian counties submitted satisfaction data. The patient response rate was 61% (n = 793). Consultations were provided in 27 specialties. The responses to the questionnaires indicated that telemedicine made it easier for patients to receive specialty care (91% of patients satisfied, mean score 4.6). There was general satisfaction with telemedicine (87%, mean 4.5), a willingness to continue receiving services (90%, mean 4.6) and most patients felt that they would not receive better care in person (61%, mean 2.3). Patients stated that they received the necessary information from specialists (85%, mean 4.5) and had their questions answered by a primary care provider or nurse (89%, mean 4.7). Seven hundred and forty-one patients submitted travel information. There was an average decrease in travel distance of 170 km and time savings of 130 min using telemedicine. The average cost of travel to a specialty appointment was $83 (n = 310). The present study suggests that telemedicine is acceptable to patients as a method of improving access to specialty expertise, and compares favourably with face-to-face care.     

The Primary Care Physician Workforce in Massachusetts: Implications for the Workforce in Rural,Small Town America

ABSTRACT: Context: Small towns across the United States struggle to maintain an adequate primary care workforce. Purpose: To examine factors contributing to physician satisfaction and retention in largely rural areas in Massachusetts, a state with rural pockets and small towns. Methods: A survey mailed in 2004‐2005 to primary care physicians, practicing in areas designated by the state as rural, queried respondents about personal and practice characteristics as well as workforce concerns. Predictors of satisfaction and likelihood of remaining in current or rural practice somewhere were assessed. Findings: Of 227 eligible physicians, 160 returned their surveys (response rate, 70.5%). Approximately one third (34.0%) reported they had grown up in communities of 100,000 or larger. Factors associated with higher overall practice satisfaction included not feeling overworked (P = .043) or professionally isolated (P = .004), and being involved in their practice (P = .045) and home communities (P = .036) as well as ease of seeking additional physicians for practice and obtaining CME credits (P = .014 and P = .017, respectively). Female physicians were more likely to report an intention to remain in rural practice somewhere for the next decade (P = .034). In rating their satisfaction with various aspects of the rural practice environment, physicians reported greatest satisfaction with their practice overall (67%) and their call group size (66%). They were least satisfied with their current (30%) and likely future income (40%). In multivariate analyses, larger practice community size was positively related to the dependent variable of overall satisfaction and negatively related to likelihood of staying in current practice or in rural practice somewhere. Conclusions: Our findings reaffirm the importance of rural medical education opportunities in physician recruitment, retention, and practice satisfaction. They also indicate that in a small New England state, a major source of physicians for rural and small town communities is physicians who have been raised in urban/suburban communities and who were trained outside of the region but who were prepared to live and to practice in rural and small town communities.     

Resultados de un programa de telemedicina para pacientes con diabetes tipo 2 en atención primaria

ObjectiveTo evaluate the impact of a telemedicine program on self-perceived health in patients with type 2 diabetes in primary care, as well as patient acceptance of and satisfaction with this program.MethodWe conducted an 18-month follow-up through telemedicine in 52 diabetic patients. The study design was non-experimental (before and after). In addition to weekly electronic transmission of fasting glucose levels, we regularly provided advice to patients about healthy habits.ResultsNo statistically significant differences were observed when mean blood glucose values were compared during follow-up. However, at the end of participation, the mean score in self-perceived health was significantly higher than at the initial assessment (70.5 ± 12.8 vs. 62.8 ± 15.0, p = 0.02). After 18 months of participation in the telemedicine program, 57.7% of patients were satisfied and 38.5% were very satisfied.ConclusionsAlthough glycemic control did not improve during the follow-up, electronic transmission of information was found to be feasible and satisfactory for patients. The patients reported a higher level of self-perceived health.     

Telegenetic medicine: improved access to services in an underserved area

We used telemedicine to improve genetics services to patients in the rural northwestern region of Florida. Patients were first seen via videoconference by a genetic counsellor, who obtained family and medical history. A local paediatrician then performed the physical examination, and a plan for evaluation was established. The videoconferencing equipment was connected at a bandwidth of 384 kbit/s, using three ISDN lines. During the first three telemedicine clinics, seven patients were evaluated and then returned to the centre for a face-to-face consultation with the clinical geneticist. No new diagnoses were made face-to-face that had not been identified by telemedicine. No diagnoses made by telemedicine were judged to be wrong when the child was evaluated face-to-face. During a two-year study of patient satisfaction with 12 telegenetics clinics, the 50 families evaluated via videoconferencing were asked to complete surveys; 40 surveys were returned (a response rate of 80%). All individuals either strongly agreed or agreed that the evaluation of their child was appropriate, sufficient and sufficiently protective of their child's privacy. The waiting time for a new patient consultation with the clinical genetics team was 16.9 months (SD 1.9) at the start and 3.0 months (SD 1.0) at the end of the trial period. The difference was significant (t-test, P < 0.0001). Telegenetics allows more rapid assurance that a genetic syndrome has not been identified, or a quicker initial evaluation and diagnosis for children who do have an identifiable genetic syndrome.     

互动感知对邀请方医生持续参与远程医疗意愿影响研究

目的：了解互动感知对邀请方医生持续参与远程医疗服务意愿的影响,为提高邀请方医生持续参与意愿、促进远程医疗发展提供参考依据。方法：通过文献分析法构建基于互动感知理论和期望确认理论的概念研究模型,采用问卷调查法,运用SPSS及AMOS软件对结构方程模型进行实证分析。结果：人机互动对感知有用性没有显著影响,人机互动显著正向影响满意度,医医互动显著影响感知有用性和满意度,感知有用性显著正向影响满意度和持续参与意愿,满意度显著正向影响持续参与意愿。结论：根据模型中的主要影响因素,分别从完善远程医疗基础设施建设、提高医生专业水平、重视远程医疗服务及其质量管理、完善利益分配机制与激励机制等方面提升邀请方医生远程医疗持续参与意愿。     

家庭医生团队应用项目管理理论对糖尿病患者开展远程健康管理的实践与思考

摘 要 “互联网+”是提升基层慢性病管理能力的有效手段,而项目管理具有集中力量办大事的优势。作为慢性病治疗和管理主力军的家庭医生团队,突破常规糖尿病管理框架,采取项目管理的形式对使用胰岛素的糖尿病患者开展远程疾病管理。本研究从计划制订、任务分解、团队分工、技术规范、知情同意、管理流程、质量控制及结果评价等方面对远程医疗管理进行全程构建与应用。经过12个月远程管理后,本社区使用胰岛素治疗的100例糖尿病患者的糖化血红蛋白、血糖控制达标率和签约服务满意率均高于管理前。家庭医生团队开展糖尿病远程健康管理,在加强质量控制和完善法规制度的基础上,具有较高的推广价值。     

Access to Patient-Centered Medical Homes in Children with Sickle Cell Disease

To determine the proportion of children with sickle cell disease (SCD) followed in a subspecialty clinic with access to a primary care provider (PCP) exhibiting practice-level qualities of a patient-centered medical home (PCMH). We surveyed 200 parents/guardians of children with SCD using a 44-item tool addressing PCP access, caregiver attitudes toward PCPs, barriers to healthcare utilization, perceived disease severity, and satisfaction with care received in the PCP versus SCD clinic settings. Individual PCMH criteria measured were a personal provider relationship and medical care characterized as accessible, comprehensive and coordinated. Although 94 % of respondents reported a PCP for their child, there was greater variation in the proportion of PCPs who met other individual PCMH criteria. A higher proportion of PCPs met criteria for coordinated care when compared to accessible or comprehensive care. In multivariate models, transportation availability, lower ER visit frequency and greater PCP visit frequency were associated favorably with having a PCP meeting criteria for accessible and coordinated care. Child and respondent demographics and disease severity had no impact on PCMH designation. Average respondent satisfaction scores for the SCD clinic was higher, when compared to satisfaction scores for the PCP. For children with SCD, access to a PCP is not synonymous with access to a medical home. While specific factors associated with PCMH access may be identified in children with SCD, their cause and effect relationships need further study.     

Frequency and management of emergencies in primary care offices: A cross-sectional study in northwestern Germany

BackgroundLittle literature exists on emergencies within primary care offices.ObjectivesWe aimed to study the occurrence of emergencies and confidence in dealing with them among primary care physicians (PCPs) in Germany.MethodsWe conducted a cross-sectional study among all PCPs with licences to practice with an own office (n = 915) in a northwestern region in Germany in 2019. Participants were asked to estimate the frequency and type of emergencies that occurred in the last 12 months in their office and about their confidence in managing emergency situations.ResultsAnswers from 375 PCPs could be analysed (response: 41.0%); 95.7% reported at least one emergency in their office within the last 12 months (mean 12.9). PCPs from rural offices reported more emergencies (on average 13.7 vs. 9.6). Acute coronary syndrome, cardiac arrhythmia and dyspnoea were the most common emergencies. A greater likelihood of feeling more confident in managing medical emergencies was found among male physicians, general internists, PCPs additionally qualified as emergency physicians and those with previous training in the emergency department and intensive care unit. In contrast, more general practitioners felt secure treating paediatric emergencies than general internists (highest level of confidence 22.1% vs. 16.3%).ConclusionIn Germany, emergencies in primary care offices occur on average once a month and more often in rural than urban areas. While most PCPs are confident in managing medical emergencies, some differences related to the training path became apparent. Ongoing training programmes may be tailored to improve emergency skills.     

A Phased Approach for the Adaptation of Telemedicine in Diabetes Management

BackgroundChronic diseases like diabetes are becoming major health care challenges in various parts of the world. The treatment of diabetes requires an integrated approach in which a team of various health care professionals works under the guidance of a diabetes specialist. If implemented appropriately, telemedicine has the potential to solve the dual problem of availability and affordability associated with health care. This paper aims to provide a phased approach to the implementation of telemedicine in diabetes care.MethodsThe study used an unstructured interview of a diabetes specialist to find out the major components of diabetes care. Once the various components of diabetes care were identified, a focus group of two physicians, two diabetes educators, and one dietician was formed to identify the various factors affecting telemedicine adaptation. The same focus group was used to find the rating of 13 identified components for three identified factors. Finally, components of diabetes care were divided into homogeneous groups, using the hierarchical clustering method.ResultsThis study identifies thirteen components of diabetes care and rates these components based on three factors, namely (1) importance (2) physical presence, and (3) frequency. k-means clustering was used to divide these components into two groups, (1) appropriate for telemedicine (ATM) and (2) not appropriate for telemedicine (NATM).DiscussionThe components of diabetes care, which are appropriate for telemedicine, can be delivered using telemedicine first. The paper gives a phased approach for the adaptation of telemedicine in case of a chronic disease like diabetes. The phased approach reduces the risks associated with implementation and provides the ability to make timely adaptations.     

2016-2017年上海市社区糖尿病高危人群筛查结果分析

  目的  描述2016-2017年上海市社区居民糖尿病高危人群筛查的结果,分析糖调节受损及糖尿病患者的危险因素。  方法  选择上海市长宁区和松江区35岁及以上居民进行糖尿病风险评估,对高危人群进行体格检查和血糖检测。  结果  两个社区共完成筛查33 469人,检出糖调节受损者4 555名和糖尿病患者3 412名,检出率分别13.6%和10.2%。高危人群中,随着年龄增加,居民发生糖尿病（男:P < 0.001;女:P < 0.001）和糖调节受损（男:P < 0.001;女:P < 0.001）的风险均增加;郊区男性患糖尿病的风险低于城区男性（OR=0.873,95%CI:0.771~0.988）,而郊区女性发生糖调节受损的风险高于城区女性（OR=1.249,95%CI:1.131~1.379）;自述有糖调节受损史（男:P < 0.001;女:P < 0.001）、亲属有2型糖尿病家族史（男:P < 0.001;女:P < 0.001）、高血压（男:P < 0.001;女:P < 0.001）、血脂异常（男:P < 0.001;女:P=0.015）、体型超重/肥胖者（男:P < 0.001;女:P < 0.001）、长期静坐的生活方式的男性（P=0.002）和有多囊卵巢综合征史的女性（P=0.011）出现血糖异常的风险更高,居民的高危因素种类数越多,发生糖尿节受损和糖尿病的风险就越大（P < 0.001）。  结论  上海市社区糖尿病的发现和防治工作形势十分严峻,应继续加强对糖尿病高危人群的监测和干预,以减少糖尿病的发生。     

Barriers to Cancer Screening by Rural Appalachian Primary Care Providers

CONTEXT: Rural Appalachia has significantly higher overall cancer mortality compared with national rates, and lack of cancer screening is believed to be one of the contributing factors. Reducing the cancer disparity in this region must include strategies to address suboptimal cancer screening practices by rural Appalachian primary care providers (PCPs). PURPOSE: To identify and investigate barriers to recommending and/or performing cancer screening among rural Appalachian PCPs. METHODS: A semistructured focus group research design was used to elicit perceived barriers to recommending and/or performing cancer screening from 36 rural Appalachian PCPs (in 5 groups), including physicians, nurse practitioners, and a physician assistant. FINDINGS: Findings indicate that rural Appalachian PCPs may not be performing recommended cancer screenings for a number of reasons. Time constraints, conflicting guidelines, and perceptions that patients do not value prevention were reported barriers to cancer screening. The PCPs in this study expressed frustration in attempting to encourage cancer screening and cited patient factors such as socioeconomic status, Appalachian culture, and cancer fatalism as barriers to cancer screening. CONCLUSIONS: Rural Appalachian PCPs encounter various barriers, such as lack of time and multiple cancer screening guidelines, to incorporating cancer screening into their practice routine. The findings underscore the negative impact of some cultural factors on preventive care delivered by PCPs. Increased provider education is needed on how best to encourage cancer screening within a cultural context and should include clarification and understanding of current cancer screening guidelines.     

Physician perceptions of the effect of telemedicine on rural retention and recruitment

We conducted a postal survey of 140 family and community specialist physicians in a predominantly rural area which had received clinical telemedicine services and videoconferenced continuing medical education (CME) for two years. The questionnaire contained 46 items. The response rate was 47%. Most respondents (83%) reported having attended videoconferenced CME sessions and 45% reported having referred patients for teleconsultation. Physicians in more rural areas used these services more frequently. Ratings of two statements assessing the value of telemedicine in community support were significantly and positively correlated with the number of videoconferenced CME sessions attended and the number of telemedicine services used. In relation to their decision to stay in their community for at least one year, respondents rated telemedicine lower in importance than all but one of 17 other factors expected to influence physician recruitment and retention in rural communities. The influences on physician rural recruitment and retention are complex. However, telemedicine was used more frequently by the more rural physicians, and there was a relationship between higher usage and higher ratings of its value as a community support.