Journal of Telemedicine and Telecare

The aim of this review was to systematically evaluate the available evidence on the effectiveness of internet-based telerehabilitation among patients after total joint arthroplasty regarding pain, range of motion, physical function, health-related quality of life, satisfaction, and psychological well-being.

This was a systematic review with meta-analysis based on the Cochrane Handbook for Systematic Reviews of Interventions guidelines. Studies published in English or Chinese were searched using defined search periods, databases, and search terms. Two reviewers assessed independently the quality of studies. RevMan 5.3 was used for meta-analysis. Heterogeneity was assessed using the χ² and I² statistic. A random effect model and mean difference (MD) with 95% confidence interval (CI) was adopted. Standardised mean difference (SMD) was used if the outcome was measured by different scales.

Eleven studies with 1020 participants were analysed. Compared to face-to-face rehabilitation, internet-based telerehabilitation showed no significant difference in outcomes of pain (SMD–0.11, 95% CI–0.32 to 0.10), range of motion in flexion (MD 0.65, 95% CI–1.18 to 2.48) and extension (MD–0.38, 95% CI–1.16 to 0.40), patient-reported physical function (SMD 0.01, 95% CI–0.15 to 0.17), health-related quality of life (SMD–0.09, 95% CI–0.26 to 0.07), satisfaction (SMD–0.04, 95% CI–0.21 to 0.14), and psychological well-being (SMD 0.10, 95% CI–0.13 to 0.33). Internet-based telerehabilitation showed better outcomes in physical functional tests (SMD–0.54, 95% CI–1.08 to–0.01).

This review suggests that internet-based telerehabilitation has comparable effectiveness to face-to-face rehabilitation on rehabilitation outcomes among patients after total joint arthroplasty.

Chronic hepatitis B (CHB) remains common in endemic regions, causing significant healthcare burden. Patients with CHB may need to be adherent to nucleoside analogue (NA) for a long period of time to prevent complications. This study aims to investigate the safety, efficacy and patient experience of a virtual monitoring clinic (VMC) in monitoring stable patients taking NA for CHB.

Patients on NA and regular follow-up were randomised to either VMC alternating with doctors’ clinic visit or to a control group in which they continued standard follow-up by doctors. Therapy adherence was measured by medication possession ratio (MPR) for NA therapy, incidence of virological breakthrough and hepatocellular carcinoma (HCC) development at two years of follow-up. Patient acceptance was measured on a Likert scale of 1–10.

A total 192 patients completed follow-up: 94 and 98 patients in the VMC and control groups, respectively. Mean age was 60.6 ± 10.8 years, with 95.3% Chinese ethnicity and 64.1% males. Age, gender, race, educational, employment and financial status were similar in both groups. Upon study completion, the majority of patients – 76 (80.9%) in VMC group and 74 (75.5%) in control group – had MPR ≥0.8; 88.8% were satisfied and rated VMC better than a traditional follow-up clinic with doctors only. More than 85% of patients rated ≥8/10 on the Likert scale for VMC, and preferred VMC over traditional clinic visits. Clinical outcomes observed were HCC development in one (1.1%) in the VMC group and four (4.1%) in the control group (p = 0.369). Two (2.1%) and one (1.0%) virological breakthroughs were observed in the VMC and control groups, respectively (p = 0.615). No incidence of HCC or abnormal blood tests were missed in the VMC arm.

VMC is a viable and safe clinical model for monitoring stable CHB patients on NA therapy without compromising patients’ adherence to medications and is preferred by patients.

Few studies have reported information related to the cost-effectiveness of traditional face-to-face treatments for aphasia. The emergence and demand for telepractice approaches to aphasia treatment has resulted in an urgent need to understand the costs and cost-benefits of this approach.

Eighteen stroke survivors with aphasia completed community-based aphasia telerehabilitation treatment, utilizing the Language-Oriented Treatment (LOT) delivered via Webex videoconferencing program. Marginal benefits to treatment were calculated as the change in Western Aphasia Battery-Revised (WAB-R) score pre- and post-treatment and marginal cost of treatment was calculated as the relationship between change in WAB-R aphasia quotient (AQ) and the average cost per treatment. Controlling for demographic variables, Bayesian estimation evaluated the primary contributors to WAB-R change and assessed cost-effectiveness of treatment by aphasia type.

Thirteen out of 18 participants experienced significant improvement in WAB-R AQ following telerehabilitation delivered therapy. Compared to anomic aphasia (reference group), those with conduction aphasia had relatively similar levels of improvement whereas those with Broca’s aphasia had smaller improvement. Those with global aphasia had the largest improvement. Each one-point of improvement cost between US$89 and US$864 for those who improved (mean = US$200) depending on aphasia type/severity.

Individuals with severe aphasia may have the greatest gains per unit cost from treatment. Both improvement magnitude and the cost per unit of improvement were driven by aphasia type, severity and race. Economies of scale to aphasia treatment–cost may be minimized by treating a variety of types of aphasia at various levels of severity.

This research examines utilization patterns for patients using telemedicine compared to those receiving treatment conventionally. Administrative data from 2007–2016 is linked to records from the Manitoba Telehealth programme to conduct a population-level study.

Using a high dimensional propensity-weighted regression model, the study compares four utilization measures between telemedicine users and non-users. These include: ambulatory visits (number of visits to any physician), visits to primary care physicians, visits to specialists and the number of hospitalizations.

Compared to non-users, telemedicine patients showed a higher number of in-person visits. Specifically, using incidence-rate ratios, telemedicine users had 1.32 more ambulatory visits (p < 0.001; 95% confidence interval, 1.23–1.41), 1.26 more visits to primary care practitioners (p<0.001; 95% confidence interval, 1.17–1.35), 1.38 more visits to specialists (p < 0.001; 95% confidence interval, 1.19–1.61) and 1.14 more hospitalizations (p>0.1; 95% confidence interval, 0.91–1.43). These results were robust to restricted analyses for distance, regions, and chronic conditions. Those patients with frequent virtual encounters with a specialist showed a decrease of the frequency of in-person visits of the same type of care (incidence-rate ratio=0.48, p < 0.001; 95% confidence interval, 0.44–0.54).

Patterns in utilization vary between telemedicine users and non-users, with users showing a higher number of in-person visits than non-users, and only frequent users of telemedicine showing reduced in-person visits. Future investigation linking utilization patterns with patient care outcomes and costs will inform healthcare policy and clinical treatment plans.

Clinical trials have proven the efficacy of mechanical thrombectomy in stroke patients with large-vessel occlusion presenting within 24 hours of symptom onset. Extending the thrombectomy window to 24 hours resulted in a higher number of thrombectomies being performed. However, little is known about the impact of the extended thrombectomy window on the telestroke call burden.

We used the prospectively maintained database of a telestroke network covering a large geographic area in the Southeast USA. We included patients presenting between January 2015 and December 2019. We compared the characteristics and outcomes between patients who presented before and after the publication of the extended window thrombectomy trials.

A total of 9041 patients presented with stroke-like symptoms during the study period. Of these, 4995 presented after February 2018. There was no difference in the patient demographics in both groups. However, patients in the post extended window group had a lower National Institute of Health Stroke Scale on presentation (3 vs. 4; p < 0.001) and longer symptom-onset-to-door time (124 vs. 85 minutes; p < 0.001). The number of consults per month nearly doubled (200 vs. 103; p < 0.001) in the extended thrombectomy window era. Similarly, the number of mechanical thrombectomies performed per month increased from four to seven since extending the thrombectomy window (p < 0.001).

The number of telestroke consults nearly doubled after the publication of the extended thrombectomy window trials, with an increase in the number of thrombectomies performed. These findings have important operational implications for hospitals implementing telestroke call coverage.

Telehealth service provision has accelerated during the Coronavirus disease 2019 (COVID-19) pandemic. As the pandemic continues, clinical practices have discovered ways to resume operations. Opportunities exist to understand patient preferences for telehealth clinical services and to tailor offerings to different demographic groups.

We conducted a survey of patients receiving telehealth services through our outpatient practice to understand the types of healthcare services for which patients report preferences for telehealth.

We received 551 survey responses (response rate = 20.8%; 551/2650). More than half of patients indicated being ‘very likely’ to use telehealth services to refill medication(s) (67.3%), prepare for an upcoming visit (66.1%), review test results (60.3%), or receive education (54.2%). Males had lower odds of preferring telehealth services for reviewing test results (odds ratio (OR) = 0.57; 95% confidence interval (CI): 0.34–0.94) or mental health issues (OR = 0.54; 95% CI: 0.38–0.77). Respondents who received a video visit were significantly more likely than those who received a telephone visit to report preferences for using telehealth for education, care plan discussions, long-term health issues, and mental health.

Patient preferences for telehealth services vary by services provided and respondent demographics. Experience with telehealth increases the likelihood for future use of these services.

On-demand telehealth can have a high rate of patients requesting visits and dropping off without being seen by a provider, especially during the COVID-19 pandemic.

On-demand telehealth requests made to a large healthcare system in the USA between 15 March 2020 and 31 May 2020 were included for analysis with a focus on patients who were defined as left without being seen (LWBS). As part of a pilot program a registered nurse attempted to call LWBS patients within 24 hours of their telehealth request and asked if they were ok, if they sought care for their original visit reason, what that care was, or if they still needed guidance. This information and patient demographics were analyzed.

During the study period there were 21,610 completed on-demand telehealth visits and 1852 patients for whom there were LWBS attempted follow-ups. Most patients LWBS for a reason that originated from the patient and not associated with the provider or telehealth platform. The mean wait time for LWBS patients was 12.4 min compared to patients waiting 15.1 min before engaging with a provider to complete a visit. Of the 1852 total LWBS patients in the follow-up programme, 819 (44.2%) were successfully contacted with a follow-up phone call. Most of these patients (63.2%) already completed or planned to complete a telehealth visit, 13.6% indicated they no longer needed to see a provider, and 12.8% planned or already completed an in-person visit. Only 2.2% went to an emergency department.

Results suggest patients can effectively self-manage their care needs.

Tele-exercise could represent an alternative for remote care in individuals with spinal cord injury at this time of the pandemic of coronavirus disease 2019. However, the differences regarding the training loads and implementation between synchronous and asynchronous types are not yet known. The purpose of this study was to compare the implementation and training load between synchronous and asynchronous tele-exercise programs in individuals with spinal cord injury.

Forty individuals with spinal cord injury were recruited and stratified into tetraplegia and paraplegia groups. All subjects performed 3 weeks of both the synchronous and asynchronous tele-exercise programs, after two weeks of familiarization with the exercises, remote connection tools and methods to record information. The primary outcomes were training load (average daily workload and average and total weekly training load) and implementation (adherence and successful exercise recording). Demographic characteristics were obtained from participants' electronic medical records.

Weekly mean workload, total workload, adherence and successful exercise recording presented significantly higher values in the synchronous compared to asynchronous tele-exercises. Average daily workload did not present significant differences between the tele-exercises.

The training load for each training session presented no differences between synchronous and asynchronous tele-exercises. Both adherence and successful data recording showed more favourable implementation values for synchronous training, thus allowing greater weekly training loads (total and average).

Genome-wide sequencing (exome or whole genome) is transforming the care and management of paediatric patients with a rare disease because of its diagnostic capabilities. Genome-wide sequencing is most effective when both parents and the child are sequenced as a trio. Genetic counselling is recommended for all families considering genome-wide sequencing. Although telehealth is well established in genetic counselling for hereditary cancer and prenatal genetics, its use with genome-wide sequencing has not been well studied. The CAUSES Clinic at BC Children’s and Women’s Hospitals was a translational paediatric trio-based genome-wide sequencing initiative. Pre-test genetic counselling via telehealth (at a clinical site near the family’s residence) was offered to families who had been previously evaluated by a clinical geneticist. We report on the first 300 families seen in the CAUSES clinic and compare health services implementation issues of families seen via telehealth versus on-site.

Demographics, cost to families (travel and time), time to first appointment, complete trio sample accrual and diagnostic rates were studied.

Of the 300 patients, 58 (19%) were seen via telehealth and 242 (81%) were seen on-site for pre-test counselling. The mean time to completion of accrual of trio samples in the telehealth group was 56.3 (standard deviation ±87.3) days versus 18.9 (standard deviation ±62.4) days in the onsite group (p < 2.2 × 10⁻¹⁶). The mean per-family estimated actual or potential travel/time cost savings were greater in the telehealth group (Can$987; standard deviation = Can$1151) than for those seen on-site (Can$305; standard deviation = Can$589) (p = 0.0004).

Telehealth allowed for access to genome-wide sequencing for families in remote communities and for them to avoid significant travel and time costs; however, there was a significant delay to accrual of the complete trio samples in the telehealth group, impacting on time of result reporting and delaying diagnoses for families for whom genome-wide sequencing was diagnostic.