Management of patients with rheumatoid arthritis by telemedicine: connected monitoring. A randomized controlled trial

ObjectivesRheumatoid arthritis (RA) is a prevalent and disabling disease that is the source of significant direct and indirect costs. The current recommended therapeutic strategy is based on the rapid introduction of therapy with conventional Disease-Modifying Anti-Rheumatic Drugs (DMARDs) combined with regular disease monitoring by the rheumatologist. The onerous nature of such intense monitoring has motivated the development of new, less demanding strategies such as telemedicine. This study aimed to estimate the cost-effectiveness of the connected monitoring of RA patients initiating a new DMARD therapy versus conventional monitoring.MethodsAn economic evaluation based on a randomized controlled trial of 89 patients was conducted. The patients in the intervention group (n = 45) were monitored using a connected monitoring interface on a smartphone, while patients in the control group (n = 44) were conventionally monitored. Health outcomes were measured as the gain in quality-adjusted life-years (QALYs), assessed using the EuroQol-5D questionnaire. Resource use and health outcomes were collected alongside the trial and at the six-month follow-up using application data and the related clinical case manager time, visits, hospitalisations, and transport records. These outcomes were valued using externally collected data on unit costs and QALY weights.ResultsCompared to conventionally monitored patients, patients receiving connected monitoring had a slightly greater but not significant gain in the average QALY of 0.07. The economic analysis found that connected monitoring resulted in a significant cost reduction of 72€ (2927€ vs. 2999€, P < 0.01). The incremental cost-utility ratio of the intervention was equal to –1,029€ per QALY (95% CI: –32,033; +24,625) with a 97.8% chance of being cost-effective at a threshold of 30,000€ per QALY gained.ConclusionImplementing EULAR recommendations for RA patients initiating a DMARD treatment using connected monitoring is more efficient and less expensive than conventional care.Clinical trial registration numberClinicalTrials.gov (NCT03005925).     

Telemedicine in wound healing

Better care for patients and improved health care depends on the availability of good information which is accessible when and where it is needed. The development of technology, more specifically the Internet, has expanded the means whereby information can be acquired and transmitted over large distances enabling the concept of telemedicine to become a reality. Telemedicine, defined as the practise of medicine at a distance, encompasses diagnosis, education and treatment. It is a technology that many thought would expand rapidly and change the face of medicine. However, this has not happened and during the last decade although certain telemedicine applications, such as video-consulting and teleradiology, have matured to become essential health care services in some countries, others, such as telepathology, remain the subject of intensive research effort. Telemedicine can be used in almost any medical specialty although the specialties best suited are those with a high visual component. Wound healing and wound management is thus a prime candidate for telemedicine. Development of a suitable telemedical system in this field could have a significant effect on wound care in the community, tertiary referral patterns and hospital admission rates.     

Telemedicine in wound care

Telemedical wound care is one of the applications of teledermatology. We present our experience using telemedicine in the successful assessment and treatment of three patients with hard-to-heal ulcers. Three patients were seen at the PEMEX General Hospital in Veracruz, Mexico. The first patient was a 53-year-old man with hypertension, morbid obesity, chronic venous insufficiency, recurrent erysipelas, leg ulcers and lymphoedema. There was one ulcer on his left lower leg (20 x 10 cm) and one on his right leg (9 x 7 cm). The second patient was a 73-year-old woman with class III obesity and ulcers in her right leg, secondary to surgical debridement of bullous erysipelas. The third patient was a 51-year-old female with rheumatoid arthritis with one ulcer on each leg and chronic lymphostasis. Photographs with a digital camera were taken and sent weekly via email to a wound care specialist in Mexico City. The photographs allowed the expert to diagnose and evaluate the chronic wounds periodically. In the present cases, telemedicine allowed us to have a rapid evaluation, diagnosis and treatment. The images were of enough quality to be useful and small enough to be sent via regular email to the remote physician who immediately gave his feedback. The expert was confident to give therapeutic recommendations in this way, and we considered this method to be very cost-effective, saving the patient and the health care system, especially in transportation.     

Telemedicine in pediatric surgery

Importance

Telemedicine is an emerging strategy for healthcare delivery that has the potential to expand access, optimize efficiency, minimize cost, and enhance patient satisfaction.

Telemedicine in burn patients: reliability and patient preference

IntroductionBurn care is demanding and time intensive. After initial evaluation and treatment, remote follow-up of suitable patients might reduce the on-site workload and efficiency. In this study, the reliability of telemedicine assessment of burn patients and preference of patients to use telemedicine was investigated.MethodsThe study was designed as cross-sectional, and included 100 acute burn patients admitted to our burn service between 1 December 2018 and 31 May 2019. Informed consent was obtained from the patients for imaging of the burn wound. Burn wounds were evaluated in the outpatient clinic by an experienced burn specialist, and lesion images that were sent using WhatsApp were evaluated by another. Patients were offered telemedicine follow-up using WhatsApp communication without being present. The data of assessments, demographic and epidemiological data, and reasons for preference of follow-up via telemedicine were examined.ResultsThe mean age of our patients was 21.21 ± 21.7 years. The percentage of burned total body surface area was 3.66 ± 3.4 on examination and 3.44 ± 3.2 on WhatsApp and the level of concordance was very high (ICC = 0.993). The inter-rater reliability values for the face-to-face examination and telemedicine groups in terms of “burn depth” and “decision of hospitalization” was congruent. Of the patients, 61% did not choose follow up with telemedicine. Demand of face-to-face assessment by burn expert was the most common reason (60.7%). In 26 patients who chose to be followed up with telemedicine, the most common reason was “living distance from the burn center” (92.3%). The remaining 13 patients indicated they did not have a preference.ConclusionsIn the assessment of burn wounds, telemedicine and face-to-face examination resulted in agreement in terms of burn depth, decision of hospitalization and percentage of total body surface area. Although WhatsApp is a reliable method, the majority of patients preferred a face-to-face follow-up. WhatsApp application can be used in remote follow up of eligible burn patients after giving brief information about the procedure.     

Telemedicine and diabetic foot ulcer outcomes. A meta-analysis of controlled trials

Telemedicine (TM) has been advanced as an effective approach to wound care management. In this era of COVID-19 pandemic, it is paramount to assess the evidence behind the use of TM in treating diabetic foot ulcers (DFU).This meta-analysis aims at evaluating the efficacy of TM versus face-to-face attendance in managing DFU. In total, four controlled studies were included in the meta-analysis comprising 3 randomized trials. The total pooled sample comprised 816 patients (816 ulcers): 337 in TM group and 479 in the control group.The results were as follows: (a) healing rate OR was 1.35, in favor of TM (p = 0.4), (b) time to heal with means of 73 ± 24.1 days and 83.5 ± 28.4 days, for the TM and control group, respectively (p = 0.35), c) the amputation rate OR was 0.48 (p = 0.007) in favor of the TM group, d) the mortality rate OR was 1.66 (p = 0.2), and e) a trend for lesser cost than face-to-face group (p = 0.4).While future research using large-sampled controlled studies is warranted, the present meta-analysis demonstrated that treating DFU via TM could be at least as effective as to face-to-face attendance. In times where clinic visits are reduced or not possible such as during this COVID-19 pandemic and the likely-to-happen future outbreaks, TM could be a valuable alternative.     

Telemedicine to follow patients in a general surgery department. A randomized controlled trial

BackgroundTelemedicine is becoming more popular in many medical specialties but few studies have been conducted in General Surgery. This study aims to evaluate the feasibility of its introduction in this specialty.MethodsA prospective randomized clinical trial (RCT) was conducted in 200 patients to compare conventional vs telemedicine follow-up in the outpatient clinics. The primary outcome was the feasibility of telemedicine follow-up and the secondary outcomes were its clinical impact and patient satisfaction.ResultsPatients were enrolled between March 2017 and April 2018 and there were no statistically significant differences between the groups’ characteristics. The primary outcome was achieved in 90% of the conventional follow-up group and in 74% of the telemedicine group (P = 0.003). No differences were found in clinical outcomes (P = 0.832) or patient satisfaction (P = 0.099).ConclusionTelemedicine is a good complementary service to facilitate follow-up management in selected patients from a General Surgery department.     

Patient Preferences Regarding Telemedicine to In-person Consultation: A Questionnaire-Based Survey

IntroductionTelemedicine has been evolving over the last two decades; however, with the advent of the COVID 19 pandemic, its utility and acceptance have drastically increased. Most studies report increasing acceptability and satisfaction rates. This study aimed to assess patient preferences regarding telemedicine to in-person consultations and to attempt to assess the factors driving these preferences.Material and MethodsA questionnaire-based cross-sectional study was conducted for patients who had both teleconsultation and in-person consultation in the orthopedic outpatient. After obtaining consent to participate in the study, the patients were divided into broad clinical categories and responses were recorded regarding the treatment of illness by the doctor and opinions regarding telemedicine. Most questions were in yes/no or a Likert-based questionnaire. Mean, median, percentage and proportions were used for statistical analysis of the data.ResultsThe study group included 264 patients, with the majority with fractures and dislocations. Most patients (55.7%) were comfortable using the software for teleconsultation, and half the respondents found telemedicine convenient. A large percentage of the study group preferred in-person consultation to teleconsultation (58.7%), and the primary reasons for discontinuing teleconsultation were dissatisfaction during the interaction with the doctor and poor connectivity to telecommunication networks.ConclusionTelecommunication has high acceptance and satisfaction, but many factors limit its acceptance in developing countries.     

Telemedicine for pediatric surgical outpatient follow-up: A prospective,randomized single-center trial

Background and purpose

Telemedicine is gaining popularity for a variety of indications. We performed a randomized controlled trial comparing telemedical versus conventional clinic follow-up in terms of feasibility and quality.

68例人工膝关节置换术的临床特点分析

膝关节置换术在骨关节疾病中的应用非常广泛,我们针对本科到目前为止所作的68个膝关节置换术的临床特点进行分析.……     

类风湿关节炎早期滑膜切除50例

我院自 1995年 3月～ 1999年 12月对 5 0例类风湿关节炎 (ＲｈｅｕｍａｔｏｉｄＡｒｔｈｒｉｔｉｓ,ＲＡ)患者行滑膜切除术 ,取得良好疗效 ,现总结如下。1　临床资料本组 5 0例中男 12例 ,女 38例 ;年龄 18～ 5 2岁 ;病程 4～18个月。手术关节 :膝 34例 ,腕 10例 ,肘 4例 ,踝 2例。所有病人均符合 1987年美国风湿病协会修订的类风湿关节炎诊断标准[1] 。2　治疗方法2 1　手术方法采用硬膜外麻醉或臂丛麻醉 ,长期服用激素患者术前 1小时给予氢化考的松 10 0～ 2 0 0ｍｇ静滴 ,手术尽可能多地切除滑膜组织 ,尽量不切断骨与韧带组织 ,用咬骨钳…     

Telemedicine in the COVID-19 era: Taking care of children with obesity and diabetes mellitus

Severe acute respiratory syndrome coronavirus 2 infection was declared a pandemic in January 2020. Since then, several measures to limit virus transmission have been imposed; among them, home confinement has been the most severe, with drastic changes in the daily routines of the general population. The “stay at home” rule has impaired healthcare service access, and patients with chronic conditions were the most exposed to the negative effects of this limitation. There is strong evidence of the worsening of obesity and diabetes mellitus in children during this period. To overcome these issues, healthcare providers have changed their clinical practice to ensure follow-up visits and medical consultation though the use of telemedicine. Telemedicine, including telephone calls, videocalls, data platforms of shared telemedicine data platforms mitigated the negative effect of pandemic restrictions. Published evidence has documented good metabolic control and weight management outcomes in centers that performed extensive telemedicine services last year during the pandemic. This review discusses studies that investigated the use of telemedicine tools for the management of pediatric obesity and diabetes.