In-person Clinic Research Articles

Prevalence of Abortions Prior to and During the COVID-19 Pandemic in a Large Health Care System.

The coronavirus disease 2019 (COVID-19) pandemic presented patients with numerous barriers to accessing health care, including access to reproductive health services. The goal of this study was to assess the prevalence of abortion prior to versus during the COVID-19 pandemic within a large health care system to better understand if patients were able to access abortion care. This was a retrospective, data-only cohort study examining the prevalence of abortion among patients aged 15 to 44 within Kaiser Permanente Northern California (KPNC) in the first 6 months of the COVID-19 stay-at-home order (April 1 to September 30, 2020) compared with a 6-month period in the year prior to the COVID-19 pandemic (April 1 to September 30, 2019). Analyses were conducted using χ2 and t tests, with a P value < .05 considered statistically significant. The prevalence of abortion among patients at risk of pregnancy in 2019 and 2020 was identical, at 0.04% (P = .93). Baseline characteristics were similar between the 2 periods. The prevalence of smoking among patients who had an abortion in 2019 was 11.24%, compared with 9.04% in 2020 (P = .0009). Additionally, 85.80% of patients had KPNC insurance 6 months after the abortion in 2019, compared with 89.53% in 2020 (P < .0001). The prevalence of abortion remained similar prior to and during the first 6 months of the COVID-19 pandemic within KPNC. Patients seeking abortion were less likely to smoke and were more likely to have consistent insurance 6 months after their abortion in 2020 versus 2019, potentially suggesting the COVID-19 pandemic resulted in healthier behaviors and more consistent access to health care. Despite stay-at-home orders and canceling of in-person clinic visits, abortion services remained accessible to a diverse population within a large health care system.

Absorbable Sutures and Telemedicine for Patients Undergoing Trigger Finger Release.

Background In the setting of the COVID-19 pandemic, the development of care processes that reduce the need for in-person clinic visits while maintaining low complication rates is needed. The purpose of this study is to assess the outcomes of patients undergoing trigger finger release with various suture and follow-up visit types to assess the feasibility of shifting towards telemedicine-based follow-up protocols. Methods A retrospective review of 329 patients undergoing trigger finger release was performed. Patients were classified based on whether or not they received in-office follow-ups; whether they received absorbable or non-absorbable sutures; and whether they were treated using a telemedicine and absorbable suture protocol or other combination of sutures and follow-ups. Univariate statistics were performed to compare outcomes between groups. Results Patients who did not undergo in-office follow-up were more likely to experience residual stiffness or contracture (11.4% vs. 4.1%; p=0.033) but had no significant differences in 30-day reoperation, emergency department (ED) returns, wound complaints, and Quick DASH (Disabilities of the Arm, Shoulder, and Hand) scores. When comparing chromic absorbable sutures to non-absorbable sutures, those with absorbable sutures were significantly more likely to have telemedicine visits but were also more likely to have wound complaints (17.9% vs. 8.5%; p=0.022). There was no significant difference in two- and six-week pain scores, 30-day reoperation, ED returns, residual symptoms, and Quick DASH scores. When comparing patients treated using the absorbable suture and telemedicine protocol with those receiving any other type of sutureand postoperative follow-up, no significant differences in any postoperative clinical outcome measures were observed. Conclusion The results of this study demonstrate that the use of an absorbable suture and telemedicine protocol for patients undergoing trigger finger release yields similar outcomes as traditional methods of care. However, the use of absorbable sutures may result in decreased patient satisfaction with surgical wound healing.

Comparison of the Bluetooth iCOquit, piCO, and Vitalograph for the assessment of breath carbon monoxide among adults initiating smoking cessation and standardized canisters

BackgroundThe Bluetooth iCOquit enables remote biochemical verification of smoking status, but its validity among adults attempting to quit smoking is unclear. This study 1) compared the iCOquit, piCO, and Vitalograph sensors to identify device-specific bias, 2) assessed the diagnostic accuracy of the iCOquit for the overall sample and within specific subgroups (sex, race, smoking rate, menthol use), and 3) assessed the validity of iCOquit readings against standardized CO canisters. MethodsiCOquit devices were tested with human breath samples from individuals seeking treatment for combustible tobacco use (N = 93) attending an in-person clinic visit. Participants provided breath samples via the iCOquit, piCO, and Vitalograph (order randomized). iCOquit devices were also tested using 5 and 10 parts per million (ppm) canisters. ResultsThe iCOquit underestimated CO and categorized more participants as abstinent relative to the other CO sensors with human breath samples. The results suggested the iCOquit could not be used interchangeably with the other CO devices. Using a cut-off of < 6 ppm, the diagnostic accuracy of the iCOquit (specificity = 94%; sensitivity = 85%) did not vary across demographic/smoking subgroups. Canister tests with the iCOquit suggested good precision (< 1 ppm). ConclusionsThe iCOquit is an affordable option for the remote measurement of CO that provides a reasonably accurate assessment of smoking status of those attempting to quit smoking using abstinence cut-off criteria of < 6 ppm. However, compared to other CO monitors, the iCOquit may underestimate CO, thereby increasing error in assessing abstinence.

Telehealth Use in a National Pediatric Weight Management Sample During the COVID-19 Pandemic.

Background: This study aimed to assess the implementation and access to telehealth-delivered pediatric weight management (PWM) during the initial phase of the COVID-19 pandemic at six US PWM programs (PWMP) using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Methods: The COVID-19 period (COVID) was defined in this retrospective, multisite study as the time when each site closed in-person care during 2020. The Pre-COVID period (Pre-COVID) was an equivalent time frame in 2019. Patients were stratified by visit completion status. Patient characteristics for COVID and Pre-COVID were compared to examine potential changes/disparities in access to care. Results: There were 3297 unique patients included across the six sites. On average, telehealth was initiated 4 days after in-person clinic closure. Compared with Pre-COVID, COVID (mean duration: 9 weeks) yielded fewer total completed visits (1300 vs. 2157) and decreased revenue (mean proportion of nonreimbursed visits 33.30% vs. 16.67%). Among the completed visits, COVID included a lower proportion of new visits and fewer patients who were male, non-English speaking, Hispanic, or Asian and more patients who were Black or lived ≥20 miles from the program site (p < 0.05 for all). Among no-show/canceled visits, COVID included more patients who had private insurance, older age, or a longer time since the last follow-up. Conclusion: Rapid implementation of telehealth during COVID facilitated continuity of PWM care. Clinic volume and reimbursement were lower during COVID and differences in the patient population reached by telehealth emerged. Further characterization of barriers to telehealth for PWM is needed.

In-Person Clinic Visits After Laparoscopic Cholecystectomy: Lessons Learned From COVID-19 Pandemic

IntroductionThe utility of routine in-person clinic appointments after laparoscopic cholecystectomy (LC) is uncertain, especially after the increase of telehealth visits during the COVID-19 pandemic. The purpose of this study was to evaluate the utility of routine in-person follow-up for patients undergoing LC prior to changes implemented during the pandemic and to determine whether a return to routine in-person follow-up is warranted. MethodsWe retrospectively reviewed follow-up encounters for all patients undergoing LC from April 2018 to February 2020. All patients were routinely scheduled for in-person postoperative clinic follow-up 2-4 wk after discharge. Follow-up was considered nonroutine if new studies or medications were ordered, the patient was referred to the emergency department or readmitted, or malignancy was identified on pathology review. ResultsOf 661 patients undergoing LC, 449 (68%) attended their scheduled in-person postoperative appointment and 212 (32%) did not. The postoperative appointment was nonroutine for 39 patients (9% of clinic attenders). Readmission occurred in 42 patients, with no differences between clinic attenders and nonattenders (P = 0.12). Furthermore, attending a postoperative clinic visit did not affect odds of readmission (odds ratio: 0.705, 95% confidence interval: 0.368, 1.351; P = 0.29). Readmission occurred on median day 9 after discharge in both groups. ConclusionsThe incidence of nonroutine follow-up after LC is low, and attendance at follow-up clinic was not associated with reduced readmissions. A return to routinely scheduling in-person follow-up 2-4 wk after discharge may not be warranted. Telehealth visits within 1 wk of discharge after LC should be considered.

Establishing a Virtual Home Assessment Program: from Concept to Implementation as a Result of the COVID-19 Pandemic.

Environmental home assessments have traditionally been performed in-person at the homes of Children's Mercy Kansas City patients. The COVID-19 pandemic brought many challenges to the way patients interact with their healthcare providers, including home visiting programs. Reaching out to patients with high-risk asthma and immunocompromised health was still needed, despite the pandemic. This project's purpose was to develop a virtual (telemedicine) healthy home assessment protocol that would continue to meet patients' needs during the isolation resulting from the pandemic. This is a newly developing approach to performing home environmental assessments with limited published research. Research on the effective use of telemedicine as an alternative to in-person clinic visits has shown that for some health conditions telemedicine represents a useful technique to engage with patients and caregivers. For some conditions, like pediatric asthma, it provides a similar level of efficacy in disease management while providing a more efficient form of interaction. This article describes the development and delivery process, timelines of caregiver interaction, and guidelines for performing virtual home assessments. It summarizes the challenges and benefits of using a virtual process for delivering home assessment services for asthma and allergy patients. Overall, caregivers indicated they found the use of virtual technology had significant benefits for them including their personal comfort and the time efficiency gained by using virtual visits to interact with Healthy Homes Program staff.

607-P: The Impact of Telenutrition vs. In-Person Nutrition Consultations on Glycemic Control in People with Type 1 Diabetes—Data from Saudi Arabia

Background: Telehealth has the potential to improve accessibility to nutrition clinics, particularly in parts of the world where the number of certified nutritionists is limited. Here, we evaluate the impact of utilizing telehealth for nutrition consultations on glycemic control and patients satisfaction when managing people with type 1 diabetes (PwT1D). Methods: A retrospective analysis of data from 137 PwT1D referred to the nutrition clinic at King Saud University to learn carb counting (2021-2022). Participants were divided into 2 groups: 1) Telenutrition group (those who had 4 virtual &amp; 2-3 in-person visits) (n=107) and 2) In-person group (those who had 6-7 in-person &amp; no virtual visits) (n=30). Changes in hemoglobin A1C and CGM metrics from baseline to month 3 (i.e. end of the study (EOS)) were compared between the groups. At the EOS, participants were asked to fill out a satisfaction survey. Results: The reduction in A1c from baseline to EOS was comparable in both groups (1.2% and 1.1%, in the Telenutrition and In-person groups, respectively, both p&amp;lt;0.01). Likewise, the glucose time in range (TIR) increased from 53.9% at baseline to 58.5% at the EOS (p&amp;lt;0.01) in the telenutrition group and from 49.1% at baseline to 54.7% at the EOS (p=0.13) in the in-person group. This was accompanied by a significant reduction in the prandial insulin doses from baseline to EOS by 32% in the telenutrition group and 28% in the in-person group (both p&amp;lt;0.01). Majority (98%) of those who attended the telenutrition clinic reported satisfaction with the quality of healthcare provided and 97% reported that their experience with the telenutrition clinic was as satisfying or more satisfying than that in the in-person clinic. Conclusion: Telenutrition clinic is as effective in improving glycemic control in people with T1D as the traditional “in-person” nutrition clinics, and its utilization may improve patients' satisfaction and accessibility to certified nutritionists Disclosure M.Al-sofiani: Consultant; Eli Lilly and Company, Speaker's Bureau; Sanofi, Medtronic, Vitalair. S.Almuammar: None.

Understanding the Acceptability and Effect of Psychiatric Care via Telemedicine as an Alternative Option for Patients Living with Intellectual Disabilities in Group Homes

Telemedicine has become a popular alternative to in-person clinic visits in the field of psychiatry, but few studies examine the impact of telemedicine mental healthcare provided to patients with intellectual disabilities living in group homes. Our study aims to fill this gap in the literature. A ten-question survey was designed to evaluate the effect of telemedicine services on access to care, quality of care, and patient and caregiver stress. This survey was distributed to caregivers of patients living in group homes who received care at the University of Alabama Medical Center. The majority of respondents indicated that telemedicine visits improved access to care, did not result in lower quality care compared to in-person visits, and adequately addressed the needs of the patient. Our findings suggest that telemedicine is an acceptable method of delivery of healthcare for a significant proportion of caregivers of patients surveyed.

Spatial-Temporal Analysis of Gait in Amyotrophic Lateral Sclerosis Using Foot-Worn Inertial Sensors: An Observational Study

Introduction: Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that alters gait and increases the risk of falls. The current model of care involves in-person multidisciplinary clinic visits to, in part, assess alterations in gait, evaluate safety, and make recommendations for management. Clinic visits, however, are relatively infrequent, and multidisciplinary evaluations can be physically demanding for patients. To better understand how gait changes over time in those with ALS and enable healthcare providers to properly respond to these changes, remote monitoring of functional mobility would be advantageous. Methods: The objective of this study was to remotely track long-term changes in walking speed using wearable inertial measurement units (IMUs). Nine ALS patients and 6 healthy controls submitted twice-weekly home walking recordings for 24 and 4 weeks, respectively. An IMU data processing method was developed and validated against laboratory-measured walking speed. Results: For both ALS patients and healthy controls, home walking speed was less than clinic walking speed by an average of 0.19 m/s (p = 0.0024). Over 24 weeks, home walking speed significantly decreased for 5 of 9 ALS patients at an average of −0.021 m/s/months (p = 0.005). Those who eventually transitioned to using assistive device (AD) while on the study demonstrated a greater decrease in walking speed than those who did not. Conclusions: Remote longitudinal gait monitoring of ALS patients is feasible with the use of an IMU. Decreases in walking speed were detected in the majority of patients, most strongly in those who eventually transitioned to an AD. Home walking speed may more accurately represent the walking abilities of ALS patients in their real-life environments, a finding which further supports the case for remote monitoring in ALS.

A Retrospective Comparison of HIV Pre-exposure Prophylaxis (PrEP) Outcomes Between a Pharmacist-led Telehealth Clinic and In-person Clinic in a Veteran Population.

Pre-exposure prophylaxis (PrEP) reduces human immunodeficiency virus (HIV) transmission through sexual contact by at least 90% when taken as prescribed. This retrospective cohort study evaluated differences in adherence to PrEP medication and monitoring between the physician- and nurse practitioner (NP)-led in-person setting and the pharmacist-led telehealth setting among patients followed by the infectious diseases clinic at the VA Eastern Colorado Health Care System from July 2012 to February 2021. The primary outcomes were PrEP tablets filled per person-year, serum creatinine (SCr) tests per person-year, and HIV screens per person-year. Secondary outcomes included sexually transmitted infection (STI) screens per person-year and patients lost to follow-up.149 patients were included in the study, with 167 person-years in the in-person cohort and 153 person-years in the telehealth cohort. Adherence to PrEP medications and monitoring was similar between in-person and telehealth clinics. PrEP tablets filled per person-year was 324 in the in-person cohort and 321 in the telehealth cohort (RR = 0.99; 95% CI, 0.98-1.00). SCr screens per person-year was 3.51 in the in-person cohort and 3.37 in the telehealth cohort (RR = 0.96; 95% CI, 0.85-1.07). HIV screens per person-year was 3.55 in the in-person cohort and 3.38 in the telehealth cohort (RR = 0.95; 95% CI, 0.85-1.07). There were no new HIV infections. Additionally, patients were less likely to be lost to follow-up when followed via telehealth (11.9% vs. 30.0%), Χ2 (1, N = 149) = 6.85, p = 0.009. These findings indicate that pharmacist-driven delivery of PrEP via telehealth can be used to increase access to PrEP without sacrificing quality of care.

0815 Utilization of Telemedicine visits in a Pediatric Sleep Center and the Effect on PAP Adherence Rates

Abstract Introduction Although positive airway pressure (PAP) is an effective treatment for OSA, adherence is often suboptimal. Consistent follow up is needed to address barriers to adherence; however, in-person clinic attendance in our center has been low and was further reduced during the COVID-19 pandemic. Suboptimal adherence may result in cessation of reimbursement by insurance, leaving OSA untreated. Untreated OSA in children can lead to behavior and learning problems, impaired growth and cardiovascular complications. Due to the decrease in show rates, in-home telemedicine visits were offered in lieu of in-person visits. Methods A retrospective chart review was performed for children with OSA seen in the pediatric sleep clinic from March 2020 and October 2022. Subjects were excluded from analysis if they did not transition to telemedicine. Telemedicine visits were conducted in the same manner as in-person visits. PAP usage after telemedicine was compared to in-person visits. Adherence was reported as percent of total usage and percent of usage greater than four hours (U&amp;gt;4h) per night. Results Three hundred nineteen charts were reviewed of whom the majority were male (69.9%). The median age (interquartile range) at PAP initiation was 12 years (7-15). Seventy eight subjects were included in the analysis. Mean U&amp;gt;4h and total usage decreased when subjects transitioned from in-person to telemedicine visits (4.18% ± 26.7, p=0.17 (3.08% ± 22.5, p=0.23), respectively. These differences were not significant. 36 subjects (46%) had &amp;lt; ± 5% change in total adherence, 23 (29%) had &amp;gt; 5% increase in total adherence, and 19 (24%) had &amp;gt; 5% decrease. When comparing change in U&amp;gt;4h, 29 (37%) subjects had &amp;lt; ± 5% change in adherence, 22 (28%) had &amp;gt; 5% decrease, and 27 (35%) had &amp;gt; 5% increase in adherence. Conclusion There were no statistically significant differences in adherence rates between telemedicine and in-person visits. Adherence improved in some children on transition from in-person to telemedicine visits. Utilization of in-home telemedicine visits may be a useful alternative for some children treated with PAP. Further studies are needed to determine which specific patient populations may benefit most from in-home telemedicine visits. Support (if any)

Implementing physical activity vital sign as a self-reported measure of physical activity in patients with multiple sclerosis in a clinical setting.

Routinely assessing exercise levels during clinical visits may be a starting point for clinicians to support physical activity inpersons with multiple sclerosis (MS). To evaluate the feasibility and findings of routinely implementing a self-reported physical activity vital sign during clinical visits. Retrospective database review. Outpatient academic MS center. All adult patients of our MS center with confirmed MS presenting for an in-person or telemedicine clinic visit with a physician or nurse practitioner. None. A standard physical activity vital sign representing minutes per week of moderate-to-vigorous exercise was collected. Percentage of persons with MS with a recorded physical activity vital sign was retrospectively evaluated along with demographic characteristics and key findings. Ninety-three percent of patients with MS at our center had a physical activity vital sign recorded in at least one visit, and 86% at the most recent visit. Of 1560 patients with a recorded physical activity vital sign, 24.3% of patients were consistently active (≥150 min/week of exercise), 20.8% were consistently inactive (0 min/week), and the remaining 54.9% were inconsistently active. The physical activity vital sign was inversely associated with BMI (p < .001) and 25-foot walk test times (p < .001), but not associated with biological sex or age. Approximately a quarter of patients with MS with a documented physical activity vital sign met national aerobic exercise guidelines of 150 min/week per the U.S. Department of Health and Human Services. Routine implementation of the physical activity vital sign at our MS center was feasible and helped identify inactive patients who may benefit from physical activity counseling.

The environmental impact of surgical telemedicine: life cycle assessment of virtual vs. in-person preoperative evaluations for benign foregut disease.

Health care accounts for almost 10% of the United States' greenhouse gas emissions, accounting for a loss of 470,000 disability-adjusted life years based on the health effects of climate change. Telemedicine has the potential to decrease health care's carbon footprint by reducing patient travel and clinic-related emissions. At our institution, telemedicine visits for evaluation of benign foregut disease were implemented for patient care during the COVID-19 pandemic. We aimed to estimate the environmental impact of telemedicine usage for these clinic encounters. We used life cycle assessment (LCA) to compare greenhouse gas (GHG) emissions for an in-person and a telemedicine visit. For in-person visits, travel distances to clinic were retrospectively assessed from 2020 visits as a representative sample, and prospective data were gathered on materials and processes related to in-person clinic visits. Prospective data on the length of telemedicine encounters were collected and environmental impact was calculated for equipment and internet usage. Upper and lower bounds scenarios for emissions were generated for each type of visit. For in-person visits, 145 patient travel distances were recorded with a median [IQR] distance travel distance of 29.5 [13.7, 85.1] miles resulting in 38.22-39.61 carbon dioxide equivalents (kgCO2-eq) emitted. For telemedicine visits, the mean (SD) visit time was 40.6 (17.1) min. Telemedicine GHG emissions ranged from 2.26 to 2.99 kgCO2-eq depending on the device used. An in-person visit resulted in 25 times more GHG emissions compared to a telemedicine visit (p < 0.001). Telemedicine has the potential to decrease health care's carbon footprint. Policy changes to facilitate telemedicine use are needed, as well as increased awareness of potential disparities of and barriers to telemedicine use. Moving toward telemedicine preoperative evaluations in appropriate surgical populations is a purposeful step toward actively addressing our role in health care's large carbon footprint.

Impact of novel insertable cardiac monitoring system on real-world cardiac device clinic workflow

Abstract Funding Acknowledgements Type of funding sources: None. Background Insertable cardiac monitors (ICMs) continually monitor for cardiac arrhythmias, enabling appropriate therapeutic intervention. However, clinic workload to manage ICM patients can be significant. The recent LINQ II ICM system was designed with several features to streamline clinic practice, including remote reprogramming and on-demand data pull capabilities, tablet-based clinician device programmer, smartphone app-based patient monitor, patient management service, and elective data triaging service. Purpose To characterize the impact of the LINQ II ICM system on clinic workload compared to previous ICM systems. Methods A detailed workflow survey was taken by clinicians at 66 unique cardiac device clinics across UK/Ireland. The total number of ICM patients per clinic averaged 563 patients (median = 500). Respondents included cardiac physiologists (94%), cardiac nurses (4%), and physicians (2%). Results Overall, 82.5% of respondents reported that the LINQ II ICM system is more efficient compared to previous ICM workflow, with a total clinic time savings of 9.3 hours/week (Table). Use of a tablet-based device programmer was estimated to save 19.9 minutes per ICM patient during the initial device insertion and activation, while the patient management service saved 30.6 minutes per new patient on monitor set-up and education. Two-thirds (68.6%) of respondents reported that app-based patient monitoring increases efficiency of remote monitoring, attributable to fewer disconnected monitors and reduced patient calls due to information available in the app (e.g., device battery life, data transmission status). The majority (85.7%) felt that remote reprogramming increases efficiency, as remote reprogramming was estimated to save an average 20.0 minutes of staff time compared to an in-clinic reprogramming. More frequent reprogramming of device alerts also led to an average 13.5% reduction in the rate of non-actionable ICM alerts, and overall 43.1% fewer in-person clinic visits. Conclusions New ICM system features appear to streamline the clinic workflow associated with managing ICM patients, freeing up valuable clinician time to devote to patient care activities.

Feasibility of Remote Wound Care: A Pilot Study Implementing a Patient-centered Remote Wound Monitoring System Using a Smartphone Application

Regular clinical assessment is critical to optimize lower extremity wound healing. However, social, transportation, and time barriers often limit patient follow-up. We aimed to assess the feasibility of using a novel, patient-centered, remote wound monitoring application (Healthy.io Minuteful for Wound smartphone “app”) for the surveillance of lower extremity wounds. We enrolled 25 patients who presented to our outpatient multidisciplinary clinic with a lower extremity wound related to peripheral artery disease and/or diabetes. All patients underwent definitive revascularization and podiatric interventions prior to enrollment. Patients and their caregivers were instructed on wound app use and asked to perform one at-home wound scan per week for a total of 8 weeks (Fig 1). Patient engagement, wound app useability, and patient and provider satisfaction with the app were collected prospectively and reported using descriptive statistics. Twenty-five patients (mean age, 65.5 ± 13.7 years, 60.0% male, 52.0% Black, 68.0% with diabetes) were enrolled over the course of 3 months. Mean baseline wound area was 18.0 ± 15.2 cm2, 24.0% of patients were recovering from osteomyelitis, and post-surgical Wound, Ischemia, foot Infection stage was 1 in 24.0%, 2 in 40.0 %, 3 in 28.0%, and 4 in 8.00% of patients. Twenty-eight percent of patients required a borrowed smartphone, and wound scans were obtained by both patients (40.0%) and caregivers (60.0%). The mean number of wound scans acquired per patient was 0.72 ± 0.63 per week, for a total mean of 5.80 ± 5.30 scans over the course of 8 weeks. Wound app use triggered an early change in wound management for 36.0% of patients. Ninety-four percent of patients and physicians involved in the study reported the app was useful (Fig 2). The Healthy.io Minuteful for Wound app is a feasible means of remote wound monitoring for use by patients and/or their caregivers. This study is the impetus for a new randomized controlled trial investigating the efficacy of wound healing with remote wound app monitoring vs standard in-person clinic visits for the treatment of lower extremity wounds, in which we hope to show the barriers that often interfere with in-person follow-up visits will no longer interfere with proper wound care.Fig 2Post-study patient survey results documenting perceived ease of use, patient empowerment, and overall usefulness of the Healthy.io Minuteful for smartphone app.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Chronic pain management during the COVID-19 pandemic: Can telemedicine replace in-person consultation? A prospective clinical study

IntroductionThe COVID-19 pandemic forced numerous pain clinics to suspend their services. For chronic pain patients, even a temporary closure and inability to connect with their healthcare providers may result in adverse outcomes. There are serious concerns regarding worsening of physical and emotional suffering and a surge in substance abuse. Therefore, telemedicine, also called telehealth, would seem to be a reasonable alternative to in-person clinic visits during the lockdowns. However, it remains unclear whether a telemedicine consultation is adequate for diagnostic purposes and subsequent intervention planning. MethodsThis study was conducted as an open-label cohort study on new patients referred to an interdisciplinary community pain clinic focused on image-guided interventions. The primary outcome was to determine whether a video consultation was sufficient to make an initial diagnosis and plan subsequent interventions. Secondary variables included technical feasibility, patient satisfaction, calculated nonincurred cost and time-saving. Video consultations were performed using a secure videoconference system consistent with routine clinic practice. ResultsSixty-five participants were recruited, and 49 (75.4%) completed the study. Patients for whom interventional approaches were not recommended elected not to continue with clinic visits. The intra-observer agreement rate between the telemedicine and in-person encounter was 93.9% (95% CI 87.2-100) for the diagnostic codes and treatment plan. The median satisfaction score from the telemedicine encounter was seven on a scale of 0–7, and it remained 6 when the remote care experience was later compared with the in-person visit. There were considerable savings in travel time and expenses. DiscussionThe study experimentally validated the ability of telemedicine encounters to establish a diagnosis and formulate an interventional pain management plan of care. The validity of virtual consultation for complex pain care remains to be determined. It is unreasonable to expect telemedicine to completely replace clinic visits in the foreseeable future. However, judicious use of technology may facilitate timely scheduling, save time and resources, and improve satisfaction without jeopardizing the quality of care.

Telemedicine and the environment: life cycle environmental emissions from in-person and virtual clinic visits

Concern over climate change is growing in the healthcare space, and telemedicine has been rapidly expanding since the start of the COVID19 pandemic. Understanding the various sources of environmental emissions from clinic visits—both virtual and in-person—will help create a more sustainable healthcare system. This study uses a Life Cycle Assessment with retrospective clinical data from Stanford Health Care (SHC) in 2019–2021 to determine the environmental emissions associated with in-person and virtual clinic visits. SHC saw 13% increase in clinic visits, but due to the rise in telemedicine services, the Greenhouse Gas emissions (GHGs) from these visits decreased 36% between 2019 and 2021. Telemedicine (phone and video appointments) helped SHC avoid approximately 17,000 metric tons of GHGs in 2021. Some departments, such as psychiatry and cancer achieved greater GHG reductions, as they were able to perform more virtual visits. Telemedicine is an important component for the reduction of GHGs in healthcare systems; however, telemedicine cannot replace every clinic visit and proper triaging and tracking systems should be in place to avoid duplicative care.

Evaluation of approaches to recruitment of racially and ethnically diverse breast cancer patients from an integrated health care setting for collection of observational social network data.

We compared approaches to recruitment of diverse women with breast cancer in a study designed to collect complex social network data. We recruited 440 women from the Kaiser Permanente Northern California population newly diagnosed with breast cancer, either in person at a clinic, by email, or by mailed letter. In clinic and mail recruitment, women completed a brief 3-page paper survey (epidemiologic data only), and women had the option to complete a separate, longer (30-40min) personal social network survey online. In email recruitment, we administered epidemiologic and personal social network measures together in a single online survey. In email and mail recruitment, we limited the sample of non-Hispanic white (NHW) women to 30% of their total. We used descriptive analysis and multinomial logistic regression to examine odds of recruitment vs. mailed letter. Women responded to the social network surveys on average 3.7months post-diagnosis. Mean age was 59.3 (median = 61.0). In-person clinic recruitment was superior with a 52.1% success rate of recruitment compared with 35.6% by mail or 17.3% by email (χ2 = 65.9, p < 0.001). Email recruitment produced the highest completion rate (82.1%) of personal network data compared with clinic (36.5%) or mail (28.7%), (χ2 = 114.6, p < 0.001). Despite intentional undersampling of NHW patients, response rates for Asian, Hispanic, and Black women by email were lower. However, we found no significant differences in recruitment rates by race and ethnicity for face-to-face clinic recruitment vs. by letter. Letter recruitment produced the highest overall response. Mailed letter was the best approach to representative recruitment of diverse women with breast cancer and collection of social network data, and further yielded the highest absolute response.

Telehealth Utilization in High-Risk Pregnancies During COVID-19.

To determine how telehealth has influenced outcomes in high-risk obstetrics patients during the Coronavirus disease 2019 (COVID-19) pandemic. A retrospective chart review was conducted to identify patterns in both telehealth and in-person clinic visits among patients of a Maternal Fetal Medicine (MFM) department from the onset of the COVID-19 pandemic from March 2020 until October 2021. For the descriptive analysis, p-values were calculated using Wilcoxon rank sum for continuous variables and chi-square or Fisher exact (where cell n < 5) for categorical variables. Variables of interest were then tested for their univariate association with telehealth utilization using logistic regression. Variables found to meet the criterion of p < 0.2 in the univariate case were introduced into a multivariable logistic model with a backward elimination for determining variable retention. We aimed to analyze whether telehealth visits significantly impacted pregnancy outcomes. Four hundred nineteen high-risk patients visited the clinic via in-person and/or telehealth appointments during the study period: 320 patients without telehealth visits and 99 patients with telehealth visits. Care provided by telehealth visits was not found to be related to self-reported race (p = 0.81), maternal body mass index (p = 1.0), or maternal age (p = 0.53). Patients with private insurance were more likely to have telehealth visits than patients with public insurance (79.9% vs. 65.5%, p < 0.01). In univariate logistic analyses, patients with diagnoses of anxiety (p < 0.01), asthma (p = 0.03), and depression (p < 0.01), at the time care was established, were more likely to have telehealth visits. Those patients with telehealth visits did not have any statistical differences in mode of delivery (p = 0.2) or pregnancy outcomes (p = 0.12), including fetal demise, preterm delivery, or delivery at term as compared with patients with all in-office visits. In multivariable analysis, patient conditions of anxiety (p < 0.01), maternal obesity (p < 0.01), and twin pregnancy (p = 0.04) were associated with higher rates of telehealth visits. Patients with certain pregnancy complications elected to have more telehealth visits. Patients with private insurance were more likely to have telehealth visits than patients with public insurance. There are benefits for patients with certain pregnancy complications to incorporate telehealth visits in addition to regularly scheduled in-person clinic visits and may be suitable in a post-pandemic setting as well. Further research in this field is needed to better understand the impact of implementing telehealth in high-risk obstetrics patients.

Health Care Utilization During the COVID-19 Pandemic Among Individuals Born Preterm

Limited data exist on pediatric health care utilization during the COVID-19 pandemic among children and young adults born preterm. To investigate differences in health care use related to COVID-19 concerns during the pandemic among children and young adults born preterm vs those born at term. In this cohort study, questionnaires regarding COVID-19 and health care utilization were completed by 1691 mother-offspring pairs from 42 pediatric cohorts in the National Institutes of Health Environmental Influences on Child Health Outcomes Program. Children and young adults (ages 1-18 years) in these analyses were born between 2003 and 2021. Data were recorded by the August 31, 2021, data-lock date and were analyzed between October 2021 and October 2022. Premature birth (<37 weeks' gestation). The main outcome was health care utilization related to COVID-19 concerns (hospitalization, in-person clinic or emergency department visit, phone or telehealth evaluations). Individuals born preterm vs term (≥37 weeks' gestation) and differences among preterm subgroups of individuals (<28 weeks', 28-36 weeks' vs ≥37 weeks' gestation) were assessed. Generalized estimating equations assessed population odds for health care used and related symptoms, controlling for maternal age, education, and psychiatric disorder; offspring history of bronchopulmonary dysplasia (BPD) or asthma; and timing and age at COVID-19 questionnaire completion. Data from 1691 children and young adults were analyzed; among 270 individuals born preterm, the mean (SD) age at survey completion was 8.8 (4.4) years, 151 (55.9%) were male, and 193 (71.5%) had a history of BPD or asthma diagnosis. Among 1421 comparison individuals with term birth, the mean (SD) age at survey completion was 8.4 (2.4) years, 749 (52.7%) were male, and 233 (16.4%) had a history of BPD or asthma. Preterm subgroups included 159 individuals (58.5%) born at less than 28 weeks' gestation. In adjusted analyses, individuals born preterm had a significantly higher odds of health care utilization related to COVID-19 concerns (adjusted odds ratio [aOR], 1.70; 95% CI, 1.21-2.38) compared with term-born individuals; similar differences were also seen for the subgroup of individuals born at less than 28 weeks' gestation (aOR, 2.15; 95% CI, 1.40-3.29). Maternal history of a psychiatric disorder was a significant covariate associated with health care utilization for all individuals (aOR, 1.44; 95% CI, 1.17-1.78). These findings suggest that during the COVID-19 pandemic, children and young adults born preterm were more likely to have used health care related to COVID-19 concerns compared with their term-born peers, independent of a history of BPD or asthma. Further exploration of factors associated with COVID-19-related health care use may facilitate refinement of care models.