[Show abstract][Hide abstract] ABSTRACT: The etiology of cognitive impairment in heart failure (HF) is controversial and likely multifactorial. Physicians may hesitate to prescribe evidence-based HF medication because of concerns related to potential negative changes in cognition among a population that is already frequently impaired. We conducted a study to determine if prescription of evidence-based HF medications (specifically, β-blockers, angiotensin-converting enzyme inhibitors, angiotensin-receptor blocking agents, diuretics, and aldosterone inhibitors) was associated with cognition in a large HF sample.
A total of 612 patients completed baseline data collection for the Rural Education to Improve Outcomes in Heart Failure clinical trial, including information about medications. Global cognition was evaluated using the Mini-Cog.
The sample mean (SD) age was 66 (13) years, 58% were men, and 89% were white. Global cognitive impairment was identified in 206 (34%) of the 612 patients. Prescription of evidence-based HF medications was not related to global cognitive impairment in this sample. This relationship was maintained even after adjusting for potential confounders (eg, age, education, and comorbid burden).
Prescription of evidence-based HF medications is not related to low scores on a measure of global cognitive function in rural patients with HF.
The Journal of cardiovascular nursing 11/2014; · 1.81 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: -There is abundant research indicating poor physical, psychological and social functioning of patients with chronic heart failure (HF), a reality that can lead to poor health related quality of life (HRQoL). Little is known about the experience of rural HF patients.
[Show abstract][Hide abstract] ABSTRACT: Abstract The telemedicine intervention in chronic disease management promises to involve patients in their own care, provides continuous monitoring by their healthcare providers, identifies early symptoms, and responds promptly to exacerbations in their illnesses. This review set out to establish the evidence from the available literature on the impact of telemedicine for the management of three chronic diseases: congestive heart failure, stroke, and chronic obstructive pulmonary disease. By design, the review focuses on a limited set of representative chronic diseases because of their current and increasing importance relative to their prevalence, associated morbidity, mortality, and cost. Furthermore, these three diseases are amenable to timely interventions and secondary prevention through telemonitoring. The preponderance of evidence from studies using rigorous research methods points to beneficial results from telemonitoring in its various manifestations, albeit with a few exceptions. Generally, the benefits include reductions in use of service: hospital admissions/re-admissions, length of hospital stay, and emergency department visits typically declined. It is important that there often were reductions in mortality. Few studies reported neutral or mixed findings.
Telemedicine and e-Health 06/2014; · 1.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess the quality and diagnostic accuracy of pediatric sexual abuse forensic examinations conducted at rural hospitals with access to telemedicine compared with examinations conducted at similar hospitals without telemedicine support. Medical records of children less than 18 years of age referred for sexual abuse forensic examinations were reviewed at five rural hospitals with access to telemedicine consultations and three comparison hospitals with existing sexual abuse programs without telemedicine. Forensic examination quality and accuracy were independently evaluated by expert review of state mandated forensic reporting forms, photo/video documentation, and medical records using two structured implicit review instruments. Among the 183 patients included in the study, 101 (55.2%) children were evaluated at telemedicine hospitals and 82 (44.8%) were evaluated at comparison hospitals. Evaluation of state mandatory sexual abuse examination reporting forms demonstrated that hospitals with telemedicine had significantly higher quality scores in several domains including the general exam, the genital exam, documentation of examination findings, the overall assessment, and the summed total quality score (p<0.05 for each). Evaluation of the photos/videos and medical records documenting the completeness and accuracy of the examinations demonstrated that hospitals with telemedicine also had significantly higher scores in several domains including photo/video quality, completeness of the examination, and the summed total completeness and accuracy score (p<0.05 for each). Rural hospitals using telemedicine for pediatric sexual abuse forensic examination consultations provided significantly higher quality evaluations, more complete examinations, and more accurate diagnoses than similar hospitals conducting examinations without telemedicine support.
[Show abstract][Hide abstract] ABSTRACT: Patients with heart failure (HF) who live in rural areas have less access to cardiac services than patients in urban areas. We conducted a randomized clinical trial to determine the impact of an educational intervention on the composite endpoint of HF rehospitalization and cardiac death in this population.
Patients (N=602, 66 ± 13 years old, 41% female, 51% systolic HF) were randomized to one of three groups: Control (usual care), Fluid Watchers LITE or Fluid Watchers PLUS. Both intervention groups included a face-to-face education session delivered by a nurse focusing on self-care. The LITE group received two follow-up phone calls, while the PLUS group received bi-weekly calls (mean 5.3±3.6, range 1-19) until the nurse judged the patient adequately trained. Over two years of follow-up, 35% of patients (n=211) experienced cardiac death or hospitalization for HF with no difference among the three groups in the proportion that experienced the combined clinical outcome (p=0.06). Although, patients in the LITE group had reduced cardiac mortality compared to patients in the control group over the two years of follow-up (7.5% and 17.7% respectively, p=0.003), there was no significant difference in cardiac mortality between patients in the PLUS group and control.
A face-to-face education intervention did not significantly decrease the combined end-point of cardiac death or hospitalization for HF. Increasing the number of contacts between the patient and nurse did not significantly improve the outcome.
www.ClinicalTrials.gov. Identifier: NCT00415545.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE:To compare the frequency of physician-related medication errors among seriously ill and injured children receiving telemedicine consultations, similar children receiving telephone consultations, and similar children receiving no consultations in rural emergency departments (EDs).METHODS:We conducted retrospective chart reviews on seriously ill and injured children presenting to 8 rural EDs with access to pediatric critical care physicians from an academic children's hospital. Physician-related ED medication errors were independently identified by 2 pediatric pharmacists by using a previously published instrument. The unit of analysis was medication administered. The association of telemedicine consultations with ED medication errors was modeled by using hierarchical logistic regression adjusting for covariates (age, risk of admission, year of consultation, and hospital) and clustering at the patient level.RESULTS:Among the 234 patients in the study, 73 received telemedicine consultations, 85 received telephone consultations, and 76 received no specialist consultations. Medications for patients who received telemedicine consultations had significantly fewer physician-related errors than medications for patients who received telephone consultations or no consultations (3.4% vs 10.8% and 12.5%, respectively; P < .05). In hierarchical logistic regression analysis, medications for patients who received telemedicine consultations had a lower odds of physician-related errors than medications for patients who received telephone consultations (odds ratio: 0.19, P < .05) or no consultations (odds ratio: 0.13, P < .05).CONCLUSIONS:Pediatric critical care telemedicine consultations were associated with a significantly reduced risk of physician-related ED medication errors among seriously ill and injured children in rural EDs.
[Show abstract][Hide abstract] ABSTRACT: To compare the quality of care delivered to critically ill and injured children receiving telemedicine, telephone, or no consultation in rural emergency departments.
Retrospective chart review with concurrent surveys.
Three hundred twenty patients presenting in the highest triage category to five rural emergency departments with access to pediatric critical care consultations from an academic children's hospital.
Quality of care was independently rated by two pediatric emergency medicine physicians applying a previously validated 7-point implicit quality review tool to the medical records. Quality was compared using multivariable linear regression adjusting for age, severity of illness, and temporal trend. Referring physicians were surveyed to evaluate consultation-related changes in their care. Parents were also surveyed to evaluate their satisfaction and perceived quality of care. In the multivariable analysis, with the no-consultation cohort as the reference, overall quality was highest among patients who received telemedicine consultations (n = 58; β = 0.50 [95% CI, 0.17-0.84]), intermediate among patients receiving telephone consultation (n = 63; β = 0.12 [95% CI, -0.14 to 0.39]), and lowest among patients receiving no consultation (n = 199). Referring emergency department physicians reported changing their diagnosis (47.8% vs 13.3%; p < 0.01) and therapeutic interventions (55.2% vs 7.1%; p < 0.01) more frequently when consultations were provided using telemedicine than telephone. Parent satisfaction and perceived quality were significantly higher when telemedicine was used, compared with telephone, for six of the seven measures.
Physician-rated quality of care was higher for patients who received consultations with telemedicine than for patients who received either telephone or no consultation. Telemedicine consultations were associated with more frequent changes in diagnostic and therapeutic interventions, and higher parent satisfaction, than telephone consultations.
Critical care medicine 08/2013; · 6.15 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Heart failure (HF) is a potentially disabling condition requiring significant patient knowledge to manage the requirements of self-care. The need for self-care is important for all patients but particularly for those living in rural areas that are geographically remote from healthcare services.
The aim of this study was to identify the level of knowledge of rural patients with HF and the clinical and demographic characteristics associated with low levels of HF knowledge.
Baseline data from 612 patients with HF enrolled in the Rural Education to Improve Outcomes in Heart Failure trial were analyzed using the Heart Failure Knowledge Scale, the Short Test of Functional Health Literacy in Adults, and the anxiety subscale of the Brief Symptom Inventory. Multiple linear regression was used to explore the contribution of sociodemographic and clinical variables to levels of HF knowledge.
The mean (SD) age was 66 (13) years; 59% were men, and 50.5% had an ejection fraction of less than 40%. The mean (SD) percent correct on the Heart Failure Knowledge Scale was 69.5% (13%; range, 25%-100%), with the most frequent incorrect items related to symptoms of HF and the need for daily weights. The men and the older patients scored significantly lower in HF knowledge than did the women and the younger patients (P = 0.002 and 0.011, respectively). The patients with preserved systolic function also scored significantly lower than those with systolic HF (P = 0.030).
Patients who are at risk for poor self-care because of low levels of HF knowledge can be identified. Older patients, men, and, patients with HF with preserved systolic function may require special educational strategies to gain the knowledge required for effective self-care.
The Journal of cardiovascular nursing 07/2013; · 1.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Abstract Introduction: This study evaluates the financial impact of telemedicine outreach in a competitive healthcare market from a tertiary children's hospital's perspective. We compared the number of transfers, average hospital revenue, and average professional billing revenue before and after the deployment of telemedicine. Materials and Methods: This is a retrospective review of hospital and physician billing records for patients transferred from 16 hospitals where telemedicine services were implemented between July 2003 and December 2010. Hospital revenue was defined as total revenue minus operating costs. Professional billing revenue was defined as total payment received as the result of physician billing of patients' insurance. We compared the number of transfers, average net hospital revenue per year, and average professional billing revenue per year before and after the deployment of telemedicine at these hospitals. Results: There were 2,029 children transferred to the children's hospital from the 16 hospitals with telemedicine during the study period. The average number of patients transferred per year to the children's hospital increased from 143 pre-telemedicine to 285 post-telemedicine. From these patients, the average hospital revenue increased from $2.4 million to $4.0 million per year, and the average professional billing revenue increased from $313,977 to $688,443 per year. On average, per hospital, following the deployment of telemedicine, hospital revenue increased by $101,744 per year, and professional billing revenue increased by $23,404 per year. Conclusions: In a competitive healthcare region with more than one children's hospital, deploying pediatric telemedicine services to referring hospitals resulted in an increased market share and an increased number of transfers, hospital revenue, and professional billing revenue.
Telemedicine and e-Health 07/2013; 19(7):502-8. · 1.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Abstract Telehealth at the University of California Health System began as a telefetal monitoring connection with a rural hospital in 1992 and evolved to become the Center for Health and Technology (CHT) in 2000. The Center supports the vision of the University of California Davis (UC Davis) Health System-a healthier world through bold innovation. The CHT focuses on the four pillars of the academic health center: clinical services, research and scholarly work, education, and public service. Since 1996, the Center has provided more than 33,000 telemedicine consultation (excluding teleradiology, telepathology, and phone consultations) in over 30 clinical specialties and at more than 90 locations across California. Research and continuous evaluation have played an integral role in shaping the telehealth program, as well as strategic collaborations and partnerships. In an effort to expand the field of telehealth the CHT provides telehealth training for health professionals, technical specialists, and administrators. Furthermore, it also plays an integral role in workforce development through the education of the next generation of community primary care physicians through Rural Programs In Medical Education (Rural PRIME) and continuing educational programs for working health professionals through videoconferencing and Web-based modalities. The Center is supported through a variety of funding sources, and its sustainability comes from a mix of fee-for-service payment, contracts, grants, gifts, and institutional funding. Together with key partners, UC Davis has educated and informed initiatives resulting in legislation and policies that advance telehealth. Looking toward the future, UC Davis is focused on technology-enabled healthcare and supporting synergy among electronic health records, health information exchange, mobile health, informatics, and telehealth.
Telemedicine and e-Health 01/2013; · 1.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Abstract Background: Teledermatology has been used to provide increased specialty access for medically underserved communities. In California, policies enable the California Medicaid (Medi-Cal) program to provide reimbursement for both store-and-forward (S&F) and live-interactive teledermatology consultations. To assess the effectiveness of teledermatology operations for this population, understanding the referring providers' perspective is crucial. The primary objective of this study was to explore the perspective of referring primary care providers (PCPs) on teledermatology by focusing on the operational considerations, challenges, and benefits to participating in teledermatology referral in the context of the Medi-Cal population. Subjects and Methods: We conducted hour-long one-on-one interviews with 10 PCPs who refer patients to teledermatology regularly and who together serve an average aggregate referral base of 2,760 teledermatology cases yearly. Results: Of the 2,760 aggregate annual teledermatology referrals, PCPs reported that they serve predominantly uninsured or underinsured populations and participate in S&F consultations. The majority of surveyed PCPs treat common skin conditions themselves. However, these PCPs refer more patients to teledermatology consultations than in-person dermatology encounters. Several factors influence PCPs' decision to refer to teledermatology, which include complexity of the skin problem, distance to accessible dermatologist, patient's insurance, and patient's preferences. PCPs identified improved workflow, enhanced communication with dermatologists, and faster turnaround for recommendations as three areas that referring physicians would like improved in their experience with teledermatology. Conclusions: Understanding the referring provider's perspective and subsequently adopting policy and practice solutions to address their challenges are vital to prompting further teledermatology participation for underserved communities.
Telemedicine and e-Health 08/2012; 18(8):580-4. · 1.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Abstract Objective: Medication errors contribute to a significant number of fatal and nonfatal adverse medical events each year. Many actions, from both a policy and innovation standpoint, have been taken to reduce medication errors in the inpatient setting; yet, these actions often target larger urban hospitals. Rural hospitals face many more challenges in implementing these changes due to fewer resources and lower patient volumes. Our article discusses the implementation and results of a telepharmacy demonstration implemented between the University of California Davis Health System and six rural hospitals. Materials and Methods: A retrospective chart review obtained baseline medication errors for comparison with the prospective review of medication orders through telepharmacy. Medication orders from rural hospitals were transmitted via fax to the University of California Davis Pharmacy for after-hours review. If a medication required after-hours removal from the pharmacy, it was requested that video verification by a telepharmacist be used to verify that the correct medication was removed from the pharmacy. Results: Baseline findings from the retrospective chart review indicated that 30.0% of patients had one or more medication errors and that these errors occurred in 7.2% of the medication orders. None of these errors were found to have resulted in harm to the patients. During the telepharmacy demonstration, 2,378 medication orders were screened from 504 independent order review requests. In total, 58 (19.2%) patients had one or more medication errors. The errors from the telepharmacy demonstration represented potential errors that were identified through telepharmacy medication review. Conclusions: Telepharmacy represents a potential alternative to around-the-clock on-site pharmacist medication review for rural hospitals.
Telemedicine and e-Health 07/2012; 18(7):530-7. · 1.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Despite increasing practice of teledermatology in the U.S., teledermatology practice models and real-world challenges are rarely studied.
The primary objective was to examine teledermatology practice models and shared challenges among teledermatologists in California, focusing on practice operations, reimbursement considerations, barriers to sustainability, and incentives. We conducted in-depth interviews with teledermatologists that practiced store-and-forward or live-interactive teledermatology from January 1, 2007 through March 30, 2011 in California.
Seventeen teledermatologists from academia, private practice, health maintenance organizations, and county settings participated in the study. Among them, 76% practiced store-and-forward only, 6% practiced live-interactive only, and 18% practiced both modalities. Only 29% received structured training in teledermatology. The average number of years practicing teledermatology was 4.29 years (SD±2.81). Approximately 47% of teledermatologists served at least one Federally Qualified Health Center. Over 75% of patients seen via teledermatology were at or below 200% federal poverty level and usually lived in rural regions without dermatologist access. Practice challenges were identified in the following areas. Teledermatologists faced delays in reimbursements and non-reimbursement of teledermatology services. The primary reason for operational inefficiency was poor image quality and/or inadequate history. Costly and inefficient software platforms and lack of communication with referring providers also presented barriers.
Teledermatology enables underserved populations to access specialty care. Improvements in reimbursement mechanisms, efficient technology platforms, communication with referring providers, and teledermatology training are necessary to support sustainable practices.
PLoS ONE 12/2011; 6(12):e28687. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Health literacy has important implications for health interventions and clinical outcomes. The Shortened Test of Functional Health Literacy in Adults (S-TOFHLA) is a timed test used to assess health literacy in many clinical populations. However, its usefulness in heart failure (HF) patients, many of whom are elderly with compromised cognitive function, is unknown. We investigated the relationship between the S-TOFHLA total score at the recommended 7-minute limit and with no time limit (NTL).
We enrolled 612 rural-dwelling adults with HF (mean age 66.0 ± 13.0 years, 58.8% male). Characteristics affecting health literacy were identified by multiple regression. Percentage of correct scores improved from 71% to 86% (mean percent change 15.1 ± 18.1%) between the 7-minute and NTL scores. Twenty-seven percent of patients improved ≥1 literacy level with NTL scores (P < .001). Demographic variables explained 24.2% and 11.1% of the variance in % correct scores in the 7-minute and the NTL scores, respectively. Female gender, younger age, higher education, and higher income were related to higher scores.
Patients with HF may be inaccurately categorized as having low or marginal health literacy when the S-TOFHLA time limits are enforced. New ways to assess health literacy in older adults are needed.
Journal of cardiac failure 11/2011; 17(11):887-92. · 3.07 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The healthcare system is challenged by growth in demand for services that is disproportionate to the volume of service providers. New care models must be created. The revolution in communications and monitoring technologies (connected health) allows for a care model that emphasizes patient self-management and just-in-time provider interventions. Challenges to realizing this vision exist, including maturity of the technology, privacy and security and the ability of providers to customize solutions to maximize patient engagement and behavior change. In addition, provider work-flow and reimbursement must be changed to enable new care models that are focused on patient self-care and just-in-time provider interventions.
Journal of General Internal Medicine 11/2011; 26 Suppl 2:636-8. · 3.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Nowhere is information technology potentially more critical in the redesign of the health-care delivery system than in rural
and frontier areas (Institute of Medicine, 2004), where it has the potential to dramatically change the way caregiving occurs.
We are moving from health-care systems aimed at providing episodic institutional care for the treatment of illnesses to information-based
systems seeking to promote increased consumer and caregiver involvement in the prevention of illness across the life span.
Rural and frontier providers and caregivers are often faced with the need to provide a broad scope of practice with regard
to medical condition, age, socioeconomic level, culture, and gender (Rosenthal & Fox, 2000). This occurs in an environment
with far fewer specialty consultants and ancillary resources, and where a higher threshold for referral to larger centers
may exist because of distance and economics (Rosenblatt & Hart, 1999).
[Show abstract][Hide abstract] ABSTRACT: Store-and-forward (S&F) teledermatology has been used to increase patient access to dermatologic care. A major challenge to implementing S&F teledermatology is selecting secure and cost-saving applications for data capture and transmission. Detailed analyses and comparison of the major S&F teledermatology applications do not exist in the current peer-reviewed literature. The objectives of this study were to identify, evaluate, and compare the major S&F teledermatology applications in the United States to help referral and consultant sites select applications responsive to their needs.
We identified four major, commercially available S&F teledermatology applications after surveying the members of the American Telemedicine Association Teledermatology Special Interest Group and the Telemedicine Task Force of the American Academy of Dermatology. A multidisciplinary team of dermatologists, primary care physicians, and information technologists established a set of criteria used to evaluate the applications. We performed a comparative analysis of the four major S&F teledermatology applications based on the predetermined evaluation criteria.
The four major, commercially available S&F teledermatology applications evaluated in this study were Alaska Federal Health Care Access Network, Medweb, TeleDerm Solutions, and Second Opinion. All four teledermatology applications were mature and capable of addressing the basic needs of S&F teledermatology referrals and consultations. Each application adopts different approaches to organize medical information and facilitate consultations. Areas in need of improvement common to these major applications include (1) increased compatibility and integration with established electronic medical record systems, (2) development of fully integrated billing capability, (3) simplifying user interface and allowing user-designed templates to communicate recommendations and patient education, and (4) reducing the cost of the applications.
The four major S&F teledermatology applications in the United States are versatile applications capable of facilitating communication between referral and consultant sites. Continued efforts in making these applications more secure, robust, user-friendly, and affordable will contribute to wider implementation of S&F teledermatology.
Telemedicine and e-Health 05/2010; 16(4):424-38. · 1.40 Impact Factor