Current perspectives on the role of telemedicine in the management of Parkinson’s disease

An Evaluation of Virtual Care for Gestational Diabetes Using the Quadruple Aim Framework: Assessment of Patient and Provider Experience, Cost, and Clinical Outcomes

VPExam Virtual Care for Heart Failure Optimizing Transitions of Care Quality Improvement Project (VPExam QI)

Introduction: Cancer is the leading cause of death in Canada. Social distancing regulations during the COVID-19 pandemic drove the rapid transitions of health care systems from in-person to virtual cancer care. Virtual care refers to the secure usage of various forms of information and communication technologies such as phone calls, video conferencing, or patient portals to facilitate/optimize the quality of patient care. Virtual care has been shown to be effective for a variety of uses in cancer care, such as pre-treatment discussions and counselling purposes. However, recent research suggests that although virtual cancer care (VCC) can enhance access to health services for some communities, it can also exacerbate health inequities for socially disadvantaged groups such as Racialized communities that may not be able to afford necessary digital technology required for virtual care. Furthermore, older adults face additional challenges when interacting with technology including restricted ability to use technology due to physical or cognitive limitations. Although Black people in Canada are reported to have the lowest rates of access to digital health technologies, it is still unclear how race affects VCC in Canada. It is essential that VCC is delivered in a manner that meets the needs of all communities and does not exacerbate inequities between the socially advantaged and socially disadvantaged communities. The objective of this study was to better understand the VCC experience of older Black patients, their caregivers and healthcare providers. Methods: Qualitative studies are appropriate to capture the lived experiences of individuals/communities of a social phenomena such as VCC. We used a theory-informed thematic analysis, using data collected from six focus groups (N= 55 participants: 40 patients and caregivers, and 15 healthcare providers) conducted across ten Canadian provinces. Qualitative data analysis was facilitated by the Nvivo 11 software. Data was coded using the Patient Centred Care model and the Synergies of Oppression framework guided interpretation. Results: The experiences of older Black patients, their caregivers and healthcare providers in using VCC were captured in five overarching themes: Patient at the intersection of multiple systems of oppression; Shifting role of caregivers; Giving choice and choosing based on the purpose of care; Opportunity to meet health care needs through digital access; Communicating effectively through virtual care. Eight barriers to optimal VCC such as limited digital literacy, linguistic barriers in traditional African/Caribbean languages, and culturally mediated views of patients were identified. We also identified six facilitators to optimal VCC such as community-based cancer support groups, caregivers support and key features of digital technologies. Conclusion: This study suggests that efforts to improve the quality of VCC necessitates a multipronged approach that addresses barriers while leveraging culturally sensitive guides to VCC. Initiative to redesign VCC programs tailored to the needs of socially disadvantaged communities like older Black patients may improve the virtual care experience for the whole population. Public policies and practices that address issues like availability of internet in remote areas, resources to support linguistic barriers or culturally sensitive training are important in responding to the complexity of access to VCC

Background:The use of virtual care, defined as providing healthcare in ways other than in-person visits, dramatically increased during the COVID-19 pandemic to minimize infection risk and maintain care provision. However, the majority of studies evaluating the use of virtual care in oncology have focused on patients with solid tumor malignancies. Patients with hematologic malignancies represent a unique population related to their underlying malignancy and treatment, but the extent to which virtual care has been successfully integrated into clinical practice is unknown. As the demand for incorporating virtual care into routine clinical practice grows, understanding how to safely and effectively use virtual care in this specific patient population is essential.Methods:A scoping review was conducted to describe the use of virtual care in the management of patients with hematologic malignancies and to examine physician- and patient-reported outcomes based on its use. A comprehensive search strategy was used to identify articles on the use of virtual modalities (digital applications, phone visits, or video visits) to deliver routine clinical care to patients with hematologic malignancies published in English between January 2000 and April 2021 in the following databases: PubMed, Medline, EMBASE, CINAHL and Scopus. No restrictions were applied to the phase of care (surveillance, active treatment, and or survivorship). A combination of search terms to encompass hematologic malignancies and virtual care was used. Screening and data abstraction were performed by two independent reviewers (AS, AV) and conflicts were adjudicated by two additional reviewers (DR, AP). Data were extracted to assess the study design, population, setting, patient characteristics, virtual care methodology and study results.Results:A total of 350 abstracts were screened and 60 studies underwent full-text review. Of these, 15 studies met inclusion criteria (13 retrospective studies, 1 prospective pilot study, and 1 randomized controlled trial). The majority of papers were published from 2020 onward (Figure 1). Three studies found that app-based tools were effective in monitoring patient symptoms and triggering alerts which resulting in sooner follow-up if indicated. One app-based tool was also used in a resource limited country during the COVID-19 pandemic to allow for communication between hematologists and their patients. Four studies described the use of phone-based interventions for new consults and follow-up visits. Phone visits for used even in high-risk patients (for example, in 29 out of 50 patients with chronic graft-versus-host disease after allogeneic stem cell transplant). Five studies found that videoconferencing, with both physicians and oncology nurses, was highly rated by patients. Emerging themes included high levels of patient satisfaction across all domains of virtual care. Provider satisfaction scores were rated lower than patient scores, with concerns about technical issues leading to challenges with virtual care. Four studies found that virtual care allowed providers to promptly respond to patient concerns, specifically when patients were experiencing side-effects or had questions about their treatment. One study also suggested a decreased risk of death when telemedicine was used to monitor symptoms in patients with diffuse large B-cell lymphoma. There were no data addressing the impact of virtual care on costs or resource utilization.Conclusion:The use of virtual care in patients with hematologic malignancies appears to be feasible, even in high-risk populations. Patients were highly satisfied with virtual care, although providers had some challenges related to the specific technologies. More research is needed to evaluate the optimal method of integrating virtual care, informed by a wider range of patient-related outcomes, as well as the downstream consequences of this integration for patient, providers, and health systems. [Display omitted] DisclosuresPrica: Astra-Zeneca: Honoraria; Kite Gilead: Honoraria.

PurposeThis study aims to explore the rise of virtual specialty care startups and understand how the ventures leverage digital services to create a new market space. Given the high level of competition in an established industry like health care, the authors investigate the business models and competitive strategies of leading virtual specialty care startups with unicorn status (i.e. emerging, current and exited unicorns).Design/methodology/approachThe authors performed an analysis of Crunchbase data to examine whether rising virtual care ventures target specialty care. They focused on companies from the USA, Europe and Asia-Pacific. The identified virtual specialty care ventures were investigated in-depth via a multiple case study. By reviewing corporate websites, Crunchbase data and media coverage, the authors analyzed the ventures’ business models and competitive strategies.FindingsThis study demonstrates that even in established and highly competitive markets such as health care, managers and entrepreneurs can still leverage digital services to unlock new market spaces. The data analysis reveals that virtual care startups target the field of specialty care. They create a new market space by focusing on fast access to services, personalization, measurable outcomes and affordability. The majority of investigated companies pursues a platform-based business model approach.Originality/valueIn the context of an established industry like health care, this study gives insights into a new generation of virtual specialty care ventures. By investigating the ventures’ business models and competitive strategies, the authors advance a young field of research.

Gynecologic Surgical Training: Current and Future Perspectives

BackgroundPrior to the wider adoption of digital health technologies during the COVID-19 pandemic, applications of virtual care were largely limited to specialist visits and remote care using telehealth (phone or video) applications. Data sharing approaches using tethered patient portals were mostly built around hospitals and larger care systems. These portals offer opportunities for improved communication, but despite a belief that care has improved, they have so far shown few outcome improvements beyond medication adherence. Less is known about use of virtual care and related tools in the outpatient context and particularly in rural community contexts.ObjectiveThis study aims to reflect on the opportunities and barriers for sustainable virtual care through an example of a digitally enabled rural micropractice, which has provided 10%-15% virtual care since 2016 and 70% virtual care since March 2020.MethodsThree focus groups, 1 with providers (physician and medical office manager) and 2 with a total of 8 patients from a rural micropractice in British Columbia, were conducted in November 2020 and December 2020. Virtual care delivery was explored through the topics of communication approach, mixing virtual and in-person care, the practice team’s journey in developing these approaches, and provider and patient satisfaction with the care model. Interviews were transcribed, checked for accuracy against recordings, and thematically analyzed.ResultsBoth patients and providers reported ease of communication and high satisfaction. Either could initiate communication, and patients found the ability to share health information asynchronously through the portal allowed time to reflect and prepare their thoughts. Patients were highly engaged and reported feeling empowered and true partners in their health care, although they noted limited care coordination with specialists. The mix of virtual and in-person visits was highly regarded by patients and providers, and patients reported feeling safe and cared for 24/7, although both expressed concern about work spilling into the provider’s home life. The physician worried about missed diagnoses with virtual care. With respect to establishing the micropractice, solutions took about 5 years to optimize, with providers noting a learning curve requiring technical support for both themselves and their patients and a willingness to respond to patient feedback to identify the best solutions. Despite a mature virtual practice, patients reported deferred care due to COVID-19.ConclusionsThe micropractice’s hybrid care model encouraged patients to be true partners in their care and resulted in high patient engagement and satisfaction; yet, success may rely on the patient population being willing to engage and being comfortable with technology. Barriers lie in gaps in care coordination and provider fear that signs or symptoms more evident with an in-person exam could be missed. Even in this setting, deferral of care in light of COVID-19 was present, and opportunities to address care gaps should be sought.

There is increasing interest from cancer patients and their healthcare providers in the use of virtual care in routine clinical practice. In the setting of hematologic malignancy, where patients often undergo complex and immunodepleting treatments, understanding how to use virtual care safely and effectively is critically important. We aimed to describe the use of virtual care in patients with hematologic malignancies and to examine physician- and patient-reported outcomes in the form of a systematic scoping review. An electronic search of PubMed, Ovid MEDLINE, Elsevier Embase, Scopus, and EBSCO CINAHL was conducted from January 2000 to April 2021. A comprehensive search strategy was used to identify relevant articles, and data were extracted to assess the study design, population, setting, patient characteristics, virtual care platform, and study results. Studies were included if they described the use of virtual care for patients with hematologic malignancies; commentaries were excluded. Fifteen studies met the inclusion criteria after abstract and full-text review. Three studies found that app-based tools were effective in monitoring patient symptoms and triggering alerts for more urgent follow-up. Four studies described the use of phone-based interventions. Five studies found that videoconferencing, with both physicians and oncology nurses, was highly rated by patients. Emerging themes included high levels of patient satisfaction across all domains of virtual care. Provider satisfaction scores were rated lower than patient scores, with concerns about technical issues leading to challenges with virtual care. Four studies found that virtual care allowed providers to promptly respond to patient concerns, especially when patients were experiencing side-effects or had questions about their treatment. Overall, the use of virtual care in patients with hematologic malignancies appears feasible, and resulted in high patient satisfaction. Further research is needed in order to evaluate the optimal method of integrating virtual care into clinical practice.

Background: The COVID-19 pandemic increased the use of virtual health care. However, certain factors may disparately affect some patients' utilization of virtual care. Associations between age, racial categories (White or Black), and socioeconomic disadvantage were evaluated during the early COVID-19 pandemic. Methods: This cross-sectional retrospective study included adult patients with virtual or in-person primary care encounters at a large, midwestern hospital system with widespread urban and suburban offices between March 1, 2020, and June 30, 2020. Virtual visits included synchronous video and telephone visits and asynchronous patient portal E-visits. Chi-squared tests and multivariable logistic analysis assessed the associations between ages and racial categories, and area deprivation index with the use of virtual versus in-person primary care. Results: Of 72,153 patient encounters, 43.0% were virtual visits, 54.6% were White patients, and 45.4% were Black. Across equivalent age ranges, black patients were slightly less likely to utilize virtual care than similarly aged White patients, but not consistently across virtual modalities. Women were more likely to use virtual care across all modalities, and individuals >65 years were more likely to use telephone visits and less likely to use video and E-visits, regardless of race. Patients residing in areas with the greatest socioeconomic advantage were more likely to utilize video and E-visits. Conclusions: Differential patterns of utilization emerged across racial categories and age ranges, suggesting that racial disparities are exacerbated depending upon patient age and mode of utilization.

IntroductionIn response to COVID-19, paediatric providers have shifted to providing outpatient health care appointments through telehealth.ObjectivesWhile research has been published previously on this topic, we felt it important to add current Canadian youth perspectives to the mix, specifically on changes due to COVID-19.MethodsSemi-structured discussions were held on virtual care in June and October 2020 with our youth members, who are patients with various health conditions, aged 13 to 19 years which allowed us to glean their unique opinions regarding virtual care in the midst of a pandemic.ResultsYouth who contributed to this commentary reported that major benefits of virtual care included time savings, ease of access, continuity of care, and ability to participate in health appointments from the comfort of one’s own home without a risk of COVID-19 exposure. These youth also recognized limitations to virtual care, including the inability to complete laboratory or imaging tests, and the lack of physical examination capabilities.ConclusionsAdditionally, they stressed the importance of visual components of virtual appointments and health care providers needing to consider privacy restrictions youth may have. Overall, our cohort of youth feel positive about virtual care and hope care providers can work with youth individually to determine the best solution for them.DisclosureNo significant relationships.

SUDDEN DEATH Triathlons more risky for men than marathons

A87 HEALTHCARE PROVIDER SATISFACTION WITH VIRTUAL CARE DELIVERY IN ALBERTA DURING THE COVID-19 PANDEMIC.

IntroductionInterest in virtual care has grown, but evidence surrounding its use for burn injuries is variable. This systematic review assesses the impact of virtual burn care in the past decade (2010-2020) by providing an overview of recent advances in the field. Data on efficacy, feasibility, cost-effectiveness, usability, pros/cons, satisfaction/acceptability, clinical outcomes, and triage effects are presented. Conclusions on its post-pandemic sustainability are drawn.MethodsA systematic review with qualitative synthesis was performed according to PRISMA guidelines. Quality of included studies was assessed by validated tools. CINAHL, OVID MEDLINE, APA PsycINFO, and the CENTRAL trials registry were searched. Grey literature was searched for in OAIster, Duck Duck Go, Bandolier Knowledge, LILACS and McMaster Health Systems Evidence. Primary literature published between 01/01/2010-12/31/2020 investigating any of the noted outcomes of interest was retrieved for data extraction.ResultsA total of 486 studies were identified for screening. 412 and 26 citations were excluded in title/abstract and full text screening, respectively. After removing 8 unretrievable works and 3 straggling duplicates, 50 citations were included. Most works were published from 2016-2020 (n=35, 70%). The most common uses (with some overlap) were acute assessment (n=35, 70%), remote follow-up (n=18, 36%) and tele-rounding (n=4, 8%). Remote photographic burn size (not depth) estimation was found feasible and acceptably accurate. Patient and provider satisfaction was high overall. Patient outcomes with virtual follow-ups were largely comparable to equivalent in-person services, though some adjunct programs saw little benefit. Increased specialist access, more accurate assessment/triage and saved travel time/cost were commonly noted. Challenges included logistics and language barriers for international interventions, IT issues and internet access limitations, HIPAA compliance and some wound/scar assessment challenges (e.g. burn depth and scar vascularity).ConclusionsEvidence suggests that virtual burn care is largely safe, efficacious and could be feasible for continued use post-COVID-19 provided technological infrastructure is attainable and suitable regulation exists. Virtual acute specialist burn assessment is particularly well supported.

Patient Discharge Instructions in the Emergency Department and Their Effects on Comprehension and Recall of Discharge Instructions: A Systematic Review and Meta-analysis

To compare the completeness of Emergency Department (ED) discharge instructions before and after introduction of an electronic discharge instructions module by scoring compliance with the Centers for Medicare and Medicaid Services (CMS) Outpatient Measure 19 (OP-19). We performed a quasi-experimental study examining the impact of an electronic discharge instructions module in an academic ED. Three hundred patients discharged home from the ED were randomly selected from two time intervals: 150 patients three months before and 150 patients three to five months after implementation of the new electronic module. The discharge instructions for each patient were reviewed, and compliance for each individual OP-19 element as well as overall OP-19 compliance was scored per CMS specifications. Compliance rates as well as risk ratios (RR) and risk differences (RD) with 95% confidence intervals (CI) comparing the overall OP-19 scores and individual OP-19 element scores of the electronic and paper-based discharge instructions were calculated. The electronic discharge instructions had 97.3% (146/150) overall OP-19 compliance, while the paper-based discharge instructions had overall compliance of 46.7% (70/150). Electronic discharge instructions were twice as likely to achieve overall OP-19 compliance compared to the paper-based format (RR: 2.09, 95% CI: 1.75 - 2.48). The largest improvement was in documentation of major procedures and tests performed: only 60% of the paper-based discharge instructions satisfied this criterion, compared to 100% of the electronic discharge instructions (RD: 40.0%, 95% CI: 32.2% - 47.8%). There was a modest difference in medication documentation with 92.7% for paper-based and 100% for electronic formats (RD: 7.3%, 95% CI: 3.2% - 11.5%). There were no statistically significant differences in documentation of patient care instructions and diagnosis between paper-based and electronic formats. With careful design, information technology can improve the completeness of ED patient discharge instructions and performance on the OP-19 quality measure.