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In-person follow-up visit attendance after telemedicine visits
Abstract
Background:
Although Coronavirus disease 2019 rapidly increased the use of telemedicine for pediatric primary care, vaccinations, screening tests, lab draws, and other procedures still require follow-up in-person visits. We investigated in-person follow-up rates after telemedicine visits at our primary care clinic, and what patient or visit characteristics were associated with non-completion of in-person follow-up.
Methods:
A retrospective cohort study was conducted of telemedicine visits completed between April and May 2020. A manual chart review was performed to determine which encounters required a follow-up in-person visit; and was tracked through August 2020. Bivariate comparisons were performed according to completion of in-person follow-up and multivariable analysis of follow-up visit attendance was performed using Cox proportional hazards regression.
Results:
Of 500 eligible encounters, 16% did not attend at least one in-person follow-up. The median time for follow-up was 2 days (IQR: 1, 6). Patients older than 1 year of age (32%, p= <0.001) and with Medicaid insurance (83%, p=0.019) were more likely to not complete a follow-up visit. The likelihood of completion was higher for Hispanic as compared to non-Hispanic Black patients (HR: 1.65; 95% CI: 1.28, 2.12; p<0.001) and patients requiring routine screening (HR: 1.40; 95% CI: 1.04, 1.89; p=0.028).
Conclusions:
Not all required in-person follow-ups were completed after telemedicine visits, which could have negative impacts on children's health. Improving the transition between telemedicine and inperson follow-up of primary care can help ensure the quality of care provided in a telemedicine-first model.
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Introduction:
Telemedicine describes a healthcare service where physicians communicate with patients remotely using telecommunication technologies. Telemedicine is being used to provide pre-/postoperative surgical consultation and monitoring as well as surgical education.
Aim:
Our purpose was to investigate the broad range of telemedicine technologies used in surgical care.
Material and methods:
MEDLINE, EMBASE, CINAHL, and Science Direct were searched for available literature from inception to March 30, 2018 with no language restrictions. The search terms included: cell phones, telemedicine, telecommunications, video, online, videoconferencing, remote consultation, surgery, preoperative, perioperative, postoperative, and surgical procedures. Studies were included if they used telemedicine in surgery for pre-, peri-, or post-surgery periods, and if they compared traditional surgical care with surgical telemedicine. We excluded case series, case reports, and conference abstracts from our review.
Results:
A total of 24 studies were included in our review. The study found that the use of telemedicine in preoperative assessment and diagnosis, evaluation after surgery and follow-up visits to be beneficial. Patients reported benefits to using telemedicine such as avoiding unnecessary trips to hospitals, saving time and reducing the number of working days missed.
Conclusion:
Telemedicine in surgical care can provide benefits to both patients and.
Background . High no-show rates can burden clinic productivity and affect patient care. Although multiple studies have shown that text messages improve appointment adherence, very little research has focused on low-income and predominantly African American populations in resident clinic settings. Objectives . To determine whether incorporating a text message reminder reduces the no-show rate at an urban, pediatric resident clinic. Methods . A randomized controlled trial was conducted at a tertiary level ambulatory pediatric practice between August 2014 and February 2015. Following a demographic survey, 170 patients were enrolled. Patients were randomized into control or intervention groups. All patients received the standard voice message appointment reminder, but the intervention group additionally received a text message reminder. The primary outcome was no-show rate. Results . 95.3% of the participants were African American, and the overall no-show rate was 30.8%. No-show rate was significantly lower in the intervention group (23.5%) than the control group (38.1%) representing a difference of 14.6% ( p=0.04 ). No demographic factors were found to alter the association between no-show rate and text message intervention. Conclusions . Text message reminders effectively improve show rates at a resident pediatric practice with high no-show rates, representing a promising approach to improving appointment adherence.
Introduction and objective
Studies on telemedicine have shown success in reducing the geographical and time obstacles incurred in the receipt of care in traditional modalities with the same or greater effectiveness; however, there are several barriers that need to be addressed in order for telemedicine technology to spread. The aim of this review is to evaluate barriers to adopting telemedicine worldwide through the analysis of published work.
Methods
The authors conducted a systematic literature review by extracting the data from the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and PubMed (MEDLINE) research databases. The reviewers in this study analysed 30 articles (nine from CINAHL and 21 from Medline) and identified barriers found in the literature. This review followed the checklist from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009. The reviewers organized the results into one table and five figures that depict the data in different ways, organized by: barrier, country-specific barriers, organization-specific barriers, patient-specific barriers, and medical-staff and programmer-specific barriers.
Results
The reviewers identified 33 barriers with a frequency of 100 occurrences through the 30 articles. The study identified the issues with technically challenged staff (11%), followed by resistance to change (8%), cost (8%), reimbursement (5%), age of patient (5%), and level of education of patient (5%). All other barriers occurred at or less than 4% of the time.
Discussion and conclusions
Telemedicine is not yet ubiquitous, and barriers vary widely. The top barriers are technology-specific and could be overcome through training, change-management techniques, and alternating delivery by telemedicine and personal patient-to-provider interaction. The results of this study identify several barriers that could be eliminated by focused policy. Future work should evaluate policy to identify which one to lever to maximize the results.
This quality improvement project aimed to reduce the 'no show' rate in a paediatric neurology clinic in Qatar.
No show, in outpatient clinics, is defined as patients who fail to attend their scheduled clinic appointments. It is one of the targets for improving quality of care. It leads to longer waiting times for patients to be seen in outpatient clinics, and the result is patients missing their important appointments. It also results in a waste of the clinic resources, and physician and other healthcare practitioners' time.
This study was undertaken as part of the CCITP (clinical care improvement training programme). A project team was assembled with coaching support. The department chairman and the appointment system personnel were involved. Baseline and ongoing measures were collected and charted.
The baseline no-show rate was identified as 49%. Following three intervention PDSAs, mainly addressing communication and appointment flexibility, the post intervention no-show rate dropped to 18% and was sustained below the target of 25% for two years.
Better communication and appointment flexibility can significantly reduce the no-show rate in outpatient clinics.
Background:
Children with care for acute illness available through the Health-e-Access telemedicine model at childcare and schools were previously found to have 22% less emergency department (ED) use than counterparts without this service, but they also had 24% greater acute care use overall.
Introduction:
We assessed the hypothesis that increased utilization reflected improved access among impoverished inner-city children to a level experienced by more affluent suburban children. This observational study compared utilization among children without and with telemedicine access, beginning in 1993, ending in 2007, and based on 84,287 child-months of billing claims-based observation.
Materials and methods:
Health-e-Access Telemedicine was initiated in stepwise manner over 187 study-months among 74 access sites (childcare, schools, community centers), beginning in month 105. Children dwelled in inner city, rest-of-city Rochester, NY, or in surrounding suburbs. Rate of total acute care visits (office, ED, telemedicine) was measured as visits per 100 child-years. Observed utilization rates were adjusted in multivariate analysis for age, sex, insurance type, and season of year.
Results:
When both suburban and inner-city children lacked telemedicine access, overall acute illness visits were 75% greater among suburban than inner-city children (suburban:inner-city rate ratio 1.75, p < 0.0001). After telemedicine became available to inner-city children, their overall acute visits approximated those of suburban children (suburban:inner-city rate ratio 0.80, p = 0.07), whereas acute visits among suburban children remained at least (worst-case comparison) 56% greater than inner-city children without telemedicine (rate ratio 1.56, p < 0.0001).
Discussion:
At baseline, overall acute illness utilization of suburban children exceeded that of inner-city children. Overall utilization for inner-city children increased with telemedicine to that of suburban children at baseline. Without telemedicine, however, inner-city use remained substantially less than for suburban counterparts.
Conclusions:
Health-e-Access Telemedicine redressed socioeconomic disparities in acute care access in the Rochester area, thus contributing to a more equitable community.
Aim:
This study examined the use of telemedicine as a means to follow up infants discharged from a Swedish neonatal intensive care unit to home healthcare.
Methods:
Families were randomised to either a control group receiving standard home healthcare (n=42 families) or a telemedicine group receiving home healthcare with telemedicine support (n=47 families) after discharge from the hospital. Both groups had follow-up hospital appointments with the neonatal nurse. In the telemedicine group, appointments were supplemented by the use of a specially designed web page and video calls.
Results:
The use of the web page and video calls decreased the number of emergency visits to the hospital (p=0.047). In the telemedicine group, 26% of the families felt they had more scheduled appointments than necessary, whereas only 6% of the families in the control group thought so (p=0.037). The parents were highly satisfied with the use of telemedicine. Although the nurses were favourable to using telemedicine, the rigid organisation of the home healthcare programme and the nurses' schedules and work routines prevented its optimal use.
Conclusions:
The use of telemedicine decreased the need of hospital visits. Organizational adaptations would be necessary to make the best use of telemedicine. This article is protected by copyright. All rights reserved.
Background and objective:
Data are limited that establish the clinical reliability of telemedicine in evaluating children who are seriously ill. Evaluation of a seriously ill child poses a challenge in that telemedicine is primarily visual, without the ability to perform a "hands-on" physical examination. Previous studies evaluating observation in assessing febrile children and children in respiratory distress have validated observation as both predictive and reliable in detecting underlying illness. The purpose of this study was to determine the interobserver reliability of telemedicine observations, compared with bedside observations, in assessing febrile children and children in respiratory distress.
Methods:
Children 2 to 36 months old presenting with a fever were evaluated by using the Yale Observation Scale; patients aged 2 months to 18 years presenting with respiratory symptoms were evaluated by using the Respiratory Observation Checklist, a list of observational signs of respiratory distress derived from validated studies and developed specifically for the present study by the authors. Telemedicine communication used commercially available tablet devices that provided 2-way, live-streamed images with audio.
Results:
A total of 132 febrile subjects were evaluated by using the Yale Observation Scale. Strong agreement (Pearson's correlation coefficient, 0.81) was found between bedside and telemedicine observers. A total of 145 subjects were evaluated by using the Respiratory Observation Checklist. Excellent agreement between bedside and telemedicine observers was found for the impression of respiratory distress (κ = .85) and good agreement (κ > .6) for the majority of the remaining components of the checklist.
Conclusions:
Telemedicine, using commercially available telecommunications equipment, is reliable in the assessment of febrile children and children with respiratory distress.
Importance
An increasing diversity of children’s health coverage options under the US Patient Protection and Affordable Care Act, together with uncertainty regarding reauthorization of the Children’s Health Insurance Program (CHIP) beyond 2017, merits renewed attention on the quality of these options for children.Objective
To compare health care access, quality, and cost outcomes by insurance type (Medicaid, CHIP, private, and uninsured) for children in households with low to moderate incomes.Design, Setting, and Participants
A repeated cross-sectional analysis was conducted using data from the 2003, 2007, and 2011-2012 US National Surveys of Children’s Health, comprising 80 655 children 17 years or younger, weighted to 67 million children nationally, with household incomes between 100% and 300% of the federal poverty level. Multivariable logistic regression models compared caregiver-reported outcomes across insurance types. Analysis was conducted between July 14, 2014, and May 6, 2015.Exposures
Insurance type was ascertained using a caregiver-reported measure of insurance status and each household’s poverty status (percentage of the federal poverty level).Main Outcomes and Measures
Caregiver-reported outcomes related to access to primary and specialty care, unmet needs, out-of-pocket costs, care coordination, and satisfaction with care.Results
Among the 80 655 children, 51 123 (57.3%) had private insurance, 11 853 (13.6%) had Medicaid, 9554 (18.4%) had CHIP, and 8125 (10.8%) were uninsured. In a multivariable logistic regression model (with results reported as adjusted probabilities [95% CIs]), children insured by Medicaid and CHIP were significantly more likely to receive a preventive medical (Medicaid, 88% [86%-89%]; P < .01; CHIP, 88% [87%-89%]; P < .01) and dental (Medicaid, 80% [78%-81%]; P < .01; CHIP, 77% [76%-79%]; P < .01) visits than were privately insured children (medical, 83% [82%-84%]; dental, 73% [72%-74%]). Children with all insurance types experienced challenges in access to specialty care, with caregivers of children insured by CHIP reporting the highest rates of difficulty accessing specialty care (28% [24%-32%]), problems obtaining a referral (23% [18%-29%]), and frustration obtaining health care services (26% [23%-28%]). These challenges were also magnified for privately insured children with special health care needs, whose caregivers reported significantly greater problems accessing specialty care (29% [26%-33%]) and frustration obtaining health care services (36% [32%-41%]) than did caregivers of children insured by Medicaid, and a lower likelihood of insurance always meeting the child’s needs (63% [60%-67%]) than children insured by Medicaid or CHIP. Caregivers of privately insured children were also significantly more likely to experience out-of-pocket costs (77% [75%-78%]) than were caregivers of children insured by Medicaid (26% [23%-28%]; P < .01) or CHIP (38% [35%-40%]; P < .01).Conclusions and Relevance
This examination of caregiver experiences across insurance types revealed important differences that can help guide future policymaking regarding coverage for families with low to moderate incomes.
For the purpose of reducing the social and economic burden imposed by common acute childhood illness, we developed a telemedicine model to enable diagnosis and treatment of illness episodes presenting in pediatric office settings. The study objective was to assess the effectiveness of this telemedicine model in replacing illness visits to traditional healthcare settings and to compare effectiveness of this model (base model) with that of alternative models including simple office laboratory tests and albuterol administration (simple model) or a complete complement of tests and procedures (extended model). Eligible subjects had an acute problem and were seen in the pediatric primary care practice or pediatric emergency department of the University of Rochester Medical Center. All subjects were seen by the setting's usual physician. Subjects were also evaluated, based on random assignment, by a study physician in person or by a study physician via telemedicine. Effectiveness was defined as completion of the visit to the point that diagnosis was made. Forms completed by study physicians, and standard medical records indicating the tests and procedures requested for the purpose of completing the visit, were used to identify the model used in completing the visit. Effectiveness (proportion of visits completed) of the base model was assessed and its effectiveness was compared to that of simple and extended telemedicine models. Among 520 randomized visits, 492 were evaluated by study physicians in person (253) or via telemedicine (239). Using the base model, study physicians completed 74.1% of visits via telemedicine compared to 76.7% for study physicians in person and 76.0% for usual physicians. The simple model increased completion rates substantially. Using this model, study physicians completed 84.9% of visits via telemedicine compared to 86.6% for study physicians in person and 85.2% for usual physicians. The extended model increased effectiveness in completing visits still more, with telemedicine study physicians completing 97.1% of visits compared to 96.8% for in-person study physicians and 100% for usual physicians. Approximately 85% of illness visits presenting to primary care pediatric practice could be completed using a telemedicine model that included only simple office laboratory testing and albuterol administration.
Objective
We analyzed the impact of geographic distance from the clinic on adherence to recommended clinic visits and diabetes control among patients with type 1 diabetes (T1D) seen in a pediatric endocrinology clinic serving a rural region in eastern North Carolina.
Methods
We retrospectively included patients with T1D age ≤20 years seen in our clinic during 2017. Outcomes were tracked until June 2018. Distance from the clinic was determined according to the zone improvement plan (ZIP) code of patient address. Visit adherence was defined based on the number of attended visits during the study period, aiming for 1 every 3 months. Glycated hemoglobin (HbA1c) was measured at the first and last visits during the review period
Results
The analysis included 368 patients, of whom 218 (59%) completed at least 1 visit every 3 months. The median HbA1c was 9.1 (interquartile range [IQR]: 8.0, 10.3) at the initial visit, and 9.3 (IQR: 8.0, 11.1) at the final visit. Median distance from the clinic was 56 km (IQR: 35, 86). On multivariable logistic regression, greater distance from the clinic was associated with lower odds of visit adherence (odds ratio per 10 km: 0.93; 95% confidence interval: 0.87, 0.99; p=0.030). Neither distance to the clinic nor clinic visit adherence were associated with HbA1c.
Conclusions
Patients living further away from the clinic were less likely to adhere to the recommended visit schedule, but distance was not correlated with HbA1c levels. Further work is needed to assist families living far from the clinic with adhering to recommended visits.
On March 13, 2020, the United States declared a national state of emergency to control the pandemic spread of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (1). Public health response measures to mitigate the pandemic have centered on social distancing and quarantine policies, including shelter-in-place and stay-at-home orders. Michigan implemented a stay-at-home order on March 23, 2020, to facilitate social distancing (2). Such strategies might result in decreased accessibility to routine immunization services, leaving children at risk for vaccine-preventable diseases and their complications (3). To evaluate whether vaccination coverage has changed during the pandemic, data from the Michigan Care Improvement Registry (the state's immunization information system) (MCIR) were analyzed. Changes in vaccine doses administered to children and the effects of those changes on up-to-date status were examined for vaccinations recommended at milestone ages corresponding to the end of an Advisory Committee on Immunization Practices (ACIP) recommendation period for one or more vaccines (4).
The use of telemedicine (TM) to deliver health care has been growing throughout the United States and internationally through asynchronous and synchronous technology. It has proven to be an effective way of delivering health care at a distance. There are multiple ways that a practice can offer these services, from direct-to-consumer to consultations in ambulatory or inpatient services. TM can be used to deliver care in homes, schools, and virtually anywhere that a patient and provider can access technology. For rural communities, emergency departments and inpatient specialty consults that were not available previously are now routine. TM also has been proven to be effective in decreasing costs to patients and increasing access in pediatrics while providing high degrees of satisfaction among patients and providers. [Pediatr Ann. 2019;48(12):e479-e484.].
Background and objectives:
Use of commercial direct-to-consumer (DTC) telemedicine outside of the pediatric medical home is increasing among children, and acute respiratory infections (ARIs) are the most commonly diagnosed condition at DTC telemedicine visits. Our objective was to compare the quality of antibiotic prescribing for ARIs among children across 3 settings: DTC telemedicine, urgent care, and the primary care provider (PCP) office.
Methods:
In a retrospective cohort study using 2015-2016 claims data from a large national commercial health plan, we identified ARI visits by children (0-17 years old), excluding visits with comorbidities that could affect antibiotic decisions. Visits were matched on age, sex, chronic medical complexity, state, rurality, health plan type, and ARI diagnosis category. Within the matched sample, we compared the percentage of ARI visits with any antibiotic prescribing and the percentage of ARI visits with guideline-concordant antibiotic management.
Results:
There were 4604 DTC telemedicine, 38 408 urgent care, and 485 201 PCP visits for ARIs in the matched sample. Antibiotic prescribing was higher for DTC telemedicine visits than for other settings (52% of DTC telemedicine visits versus 42% urgent care and 31% PCP visits; P < .001 for both comparisons). Guideline-concordant antibiotic management was lower at DTC telemedicine visits than at other settings (59% of DTC telemedicine visits versus 67% urgent care and 78% PCP visits; P < .001 for both comparisons).
Conclusions:
At DTC telemedicine visits, children with ARIs were more likely to receive antibiotics and less likely to receive guideline-concordant antibiotic management compared to children at PCP visits and urgent care visits.
Background: A shortage of pediatricians and long wait times in the hospitals render more efficient follow-up visits increasingly important. Virtual visits between physician and patient offer a solution to this problem. Increased awareness, improved technology, and efficient scheduling methods will contribute to the quality and adoption of telemedicine programs.
Introduction: The aim of this study was to analyze the impact of pediatric telemedicine on wait times and visit durations, as compared with in-person visits. A secondary goal was to assess the efficiency of different scheduling methods for virtual visits.
Materials and Methods: The study included >800 postoperative virtual visits from urology, cardiovascular surgery, and ophthalmology, comprising data on wait times, visit duration, and postvisit satisfaction collected through SBR Health and Redcap. In-person visit data were collected on 14 patients in urology, and satisfaction scores were obtained through Press Ganey for urology and ophthalmology.
Results: Patients reported very high satisfaction with virtual visits and benefitted from reduced wait times, while receiving care of comparable duration and quality. Longer blocks of time scheduled exclusively for virtual visits correlated with shorter wait times.
Discussion: Supplementing health care with telemedicine is a viable way to provide patient-centered care. Implemented effectively, a telemedicine program can contribute greatly to the value a hospital provides to its patients.
Conclusions: Virtual visits provide an efficient way to conduct postoperative visits, reducing wait times and increasing physician efficiency while retaining high satisfaction and quality of care.
Telemedicine is a technological tool that is improving the health of children around the world. This report chronicles the use of telemedicine by pediatricians and pediatric medical and surgical specialists to deliver inpatient and outpatient care, educate physicians and patients, and conduct medical research. It also describes the importance of telemedicine in responding to emergencies and disasters and providing access to pediatric care to remote and underserved populations. Barriers to telemedicine expansion are explained, such as legal issues, inadequate payment for services, technology costs and sustainability, and the lack of technology infrastructure on a national scale. Although certain challenges have constrained more widespread implementation, telemedicine's current use bears testimony to its effectiveness and potential. Telemedicine's widespread adoption will be influenced by the implementation of key provisions of the Patient Protection and Affordable Care Act, technological advances, and growing patient demand for virtual visits.
Copyright © 2015 by the American Academy of Pediatrics.
We designed a telemedicine model for diagnosis of common, acute illness to compare telemedicine and in-person evaluations on reproducibility of diagnosis and treatment.
Subjects were seen by usual physicians in ambulatory settings. Subjects were also evaluated separately by experienced general pediatricians (study physicians), either in person or via telemedicine, based on random assignment. The primary measure of reproducibility was study physician agreement with usual physician on primary diagnosis. Analysis compared reproducibility for telemedicine versus in-person evaluations. Relevance of agreement on primary diagnosis was measured by comparing agreement on prescribed medications.
Agreement on diagnosis of study physicians with usual physicians for the 492 visits studied was 89%. The difference in the proportion of visits with disagreements between telemedicine study and in-person study evaluations (13.8% vs 8.3%, respectively) bordered on significance (P = .051). Disagreement proportions for prescriptions were similar (32.2% vs 27.4%), however. Telemedicine evaluation for children with upper respiratory tract (URI)-ear symptoms involved unique technical requirements and clinical judgments. For this largest subgroup of 202 visits, disagreement on diagnosis for telemedicine occurred more often than for in-person evaluation (17.6 vs 6.3%, P < .02). For the remaining 290 visits, telemedicine and in-person study physicians disagreed on diagnosis about equally (11.5 vs 9.9%).
Excluding the URI-ear group, reproducibility of telemedicine diagnosis did not differ from that of in-person diagnosis. For the URI-ear group, reproducibility of diagnosis by telemedicine and in-person evaluation varied significantly.
This study examines national compliance rates with well-child visit recommendations using the Medical Expenditure Panel Survey. The Medical Expenditure Panel Survey provides nationally representative information on preventative care for children, combining visit-level data over a 2-year period with a rich array of socioeconomic and health status measures.
Visit-level data from 2000 to 2002 were used to construct a well-child visit "compliance" measure equal to well-child visits as a percentage of age-specific recommendations from the American Academy of Pediatrics. Compliance was examined across age, gender, race/ethnicity, health status, poverty, insurance coverage, eligibility for public coverage, family structure, parent education, insurance, citizenship and country of origin, language, urbanicity, and census division.
On average, 56.3% of all children aged 0 to 18 years had no well-child visits during a 12-month period, and 39.4% had no well-child visits over a 2-year period. The average compliance ratio was 61.4%. Large differences in compliance exist among children. High compliance rates were observed among infants (83.2%), children with special health care needs (86.6%), children with college-educated parents (74.3%), children with family incomes >4 times the poverty level (71.6%), and children in the New England (94.6%) and Middle Atlantic (83.2%) census divisions. Low levels of compliance were observed among uninsured children (35.3%) and especially uninsured children simulated to be eligible for public coverage (28.4%). Other groups with low compliance rates include teenagers (49.2%), noncitizen children (43.9%), and children in the West South Central (44.9%), East South Central (48.8%), and Mountain (49.7%) census divisions.
Well-child visit compliance in the Medical Expenditure Panel Survey is less than found in other household surveys, yet consistent with or above results based on data from provider and claims data. Although experts dispute the optimal frequency of well-child visits, the disparities observed in compliance rates among population subgroups raise important public health concerns.
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