In-person Cohort Research Articles

A retrospective review of incidental malignancies in veterans seen for face-to-face follow-up after teledermatology consultation

A retrospective review of incidental malignancies in veterans seen for face-to-face follow-up after teledermatology consultation

The Application of Telemedicine to Pediatric Obesity: Lessons from the Past Decade.

Background: Telemedicine has been utilized to deliver pediatric weight management care in both rural and urban communities. This method of health care delivery may provide a solution to the many logistical obstacles to pediatric obesity management, including time, finances, and distance to programs. Objectives: This review examines all studies in the past decade that employed telehealth communication directly between families and obesity specialists to treat pediatric obesity. To assess the practical use of such programs, studies that surveyed family satisfaction with this method of health care are also included. Methods: A comprehensive electronic database search was conducted in PubMed/MEDLINE, Scopus, CINAHL, and Cochrane Library databases. Results: All studies demonstrated noninferiority in clinical efficacy as measured by weight status improvement in participants of either the telehealth cohort or the in-person cohort. Attrition rates were also not statistically significant between groups. Patient satisfaction with telemedicine delivery was high across studies. Lack of statistical significance in outcomes of these studies can be attributed to infrequent visits, limited duration of programs, and study size. Conclusions: Future research is needed to evaluate the effect on health outcomes as well as compliance when direct to consumer telemedicine visits are integrated in pediatric weight management clinics with more frequency and for longer duration. This method of telemedicine would allow for increased contact with patients and families in between face-to-face encounters. Telehealth provides the potential to create more robust, accessible, and effective pediatric weight management programs.

Prescreening for European Prevention of Alzheimer Dementia (EPAD) trial-ready cohort: impact of AD risk factors and recruitment settings

BackgroundRecruitment is often a bottleneck in secondary prevention trials in Alzheimer disease (AD). Furthermore, screen-failure rates in these trials are typically high due to relatively low prevalence of AD pathology in individuals without dementia, especially among cognitively unimpaired. Prescreening on AD risk factors may facilitate recruitment, but the efficiency will depend on how these factors link to participation rates and AD pathology. We investigated whether common AD-related factors predict trial-ready cohort participation and amyloid status across different prescreen settings.MethodsWe monitored the prescreening in four cohorts linked to the European Prevention of Alzheimer Dementia (EPAD) Registry (n = 16,877; mean ± SD age = 64 ± 8 years). These included a clinical cohort, a research in-person cohort, a research online cohort, and a population-based cohort. Individuals were asked to participate in the EPAD longitudinal cohort study (EPAD-LCS), which serves as a trial-ready cohort for secondary prevention trials. Amyloid positivity was measured in cerebrospinal fluid as part of the EPAD-LCS assessment. We calculated participation rates and numbers needed to prescreen (NNPS) per participant that was amyloid-positive. We tested if age, sex, education level, APOE status, family history for dementia, memory complaints or memory scores, previously collected in these cohorts, could predict participation and amyloid status.ResultsA total of 2595 participants were contacted for participation in the EPAD-LCS. Participation rates varied by setting between 3 and 59%. The NNPS were 6.9 (clinical cohort), 7.5 (research in-person cohort), 8.4 (research online cohort), and 88.5 (population-based cohort). Participation in the EPAD-LCS (n = 413 (16%)) was associated with lower age (odds ratio (OR) age = 0.97 [0.95–0.99]), high education (OR = 1.64 [1.23–2.17]), male sex (OR = 1.56 [1.19–2.04]), and positive family history of dementia (OR = 1.66 [1.19–2.31]). Among participants in the EPAD-LCS, amyloid positivity (33%) was associated with higher age (OR = 1.06 [1.02–1.10]) and APOE ɛ4 allele carriership (OR = 2.99 [1.81–4.94]). These results were similar across prescreen settings.ConclusionsNumbers needed to prescreen varied greatly between settings. Understanding how common AD risk factors link to study participation and amyloid positivity is informative for recruitment strategy of studies on secondary prevention of AD.

Hospital Utilization Among Rural Children Served by Pediatric Neurology Telemedicine Clinics

Telemedicine is increasingly used to provide outpatient pediatric neurology consultations in underserved communities. Although telemedicine clinics have been shown to improve access, little is known about how they alter patients' utilization of hospital services. To evaluate the association between access to telemedicine clinics and hospital utilization among underserved children with neurologic conditions. This retrospective cross-sectional study included 4169 patients who received outpatient care from pediatric neurologists affiliated with an academic children's hospital in California between January 1, 2009, and July 31, 2017, either in person or using telemedicine. Consultation modality (telemedicine or in person) in the outpatient neurology clinics. Demographic and clinical variables were abstracted from the hospital's electronic medical records. The association between the modality of outpatient neurology care and patients' utilization of the emergency department and hospitalizations was evaluated. Both all-cause and neurologic condition-related hospital utilization were analyzed using multivariable negative binomial regression in overall and matched samples. The telemedicine cohort comprised 378 patients (211 [55.8%] male), and the in-person cohort comprised 3791 patients (2090 [55.1%] male). The mean (SD) age at the first encounter was 7.4 (5.4) years for the telemedicine cohort and 7.8 (5.1) years for the in-person cohort. The telemedicine cohort was more likely than the in-person cohort to have nonprivate insurance (public insurance, self-pay, or uninsured), lower education, and lower household income. The rates of all-cause and neurologic hospital encounters were lower among children who received pediatric neurology consultations over telemedicine compared with children who received care in the in-person clinics (5.7 [95% CI, 3.5-8.0] vs 20.1 [95% CI, 18.1-22.1] per 100 patient-years and 3.7 [95% CI, 2.0-5.3] vs 8.9 [95% CI, 7.8-10.0] per 100 patient-years, respectively; P < .001). Even after adjusting for demographic and clinical factors, the telemedicine cohort had a lower risk of hospital encounters (emergency department visits and admissions) with an adjusted incidence rate ratio of 0.57 (95% CI, 0.38-0.88) for all-cause encounters and an adjusted incidence rate ratio of 0.60 (95% CI, 0.36-0.99) for neurologic encounters. After matching on travel time to the neurology clinic, the adjusted incidence rate ratio was 0.19 (95% CI, 0.04-0.83) for all-cause admissions and 0.14 (95% CI, 0.02-0.82) for neurologic admissions. Pediatric neurology care through real-time, audiovisual telemedicine consultations was associated with lower hospital utilization compared with in-person consultations, suggesting that high-cost hospital encounters can be prevented by improving subspecialty access.

Clinically significant incidental findings among teledermatology patients with history of skin cancer

To the Editor: Store-and-forward teledermatology relies on primary care providers' (PCPs') ability to detect suspicious lesions. Incidental findings, defined as imaged lesions beyond the reason for consultation and undocumented by the referring PCP, have not yet been quantified in teledermatology. Although others have studied incidental skin cancers comparing teledermatology to in-person evaluation and found 8 of 9 incidental malignancies in patients with history of neoplasia, 1 Keleshian V. Ortega-Loayza A.G. Tarkington P. Incidental skin malignancies in teledermatology and in-person cohorts in the Veterans Affairs Health System. J Am Acad Dermatol. 2017; 77: 965-966 Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar to our knowledge none have investigated incidental lesions that were missed but visible during the consultation itself. 1 Keleshian V. Ortega-Loayza A.G. Tarkington P. Incidental skin malignancies in teledermatology and in-person cohorts in the Veterans Affairs Health System. J Am Acad Dermatol. 2017; 77: 965-966 Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar , 2 Kingsley-Loso J.L. Grey K.R. Hanson J.L. et al. Incidental lesions found in veterans referred to dermatology: the value of a dermatologic examination. J Am Acad Dermatol. 2015; 72: 651-655.e651 Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar We aimed to evaluate clinically significant incidental lesions in teledermatology consultations of veterans with a skin cancer history and factors associated with higher likelihood of lesion discovery as evidenced by teledermatologist documentation.

Appointment completion in pediatric neurology telemedicine clinics serving underserved patients.

To determine whether telemedicine improves access to outpatient neurology care for underserved patients, we compared appointment completion between urban, in-person clinics and telemedicine clinics held in rural and underserved communities where neurology consultations are provided remotely. In this retrospective study, we identified patients scheduled for outpatient care from UCDH pediatric neurologists between January 1, 2009, and July 31, 2017, in person and by telemedicine. Demographic and clinical variables were abstracted from electronic medical records. We evaluated the association between consultation modality and visit completion in overall and matched samples using hierarchical multivariable logistic regression. We analyzed 13,311 in-person appointments by 3,831 patients and 1,158 telemedicine appointments by 381 patients. The average travel time to the site of care was 45.8 ± 52.1 minutes for the in-person cohort and 22.3 ± 22.7 minutes for the telemedicine cohort. Telemedicine sites were located at an average travel time of 217.1 ± 114.8 minutes from UCDH. Telemedicine patients were more likely to have nonprivate insurance, lower education, and lower household income. They had different diagnoses and fewer complex chronic conditions. Telemedicine visits were more likely to be completed than either "cancelled" or missed ("no show") compared with in-person visits (OR 1.57, 95% CI: 1.34-1.83; OR 1.66, 95% CI: 1.31-2.10 matched on travel time to the site of care; OR 2.22, 95% CI: 1.66-2.98 matched on travel time to UCDH). The use of telemedicine for outpatient pediatric neurology visits has high odds of completion and can serve as an equal adjunct to in-person clinic visits.

Incidental skin malignancies in teledermatology and in-person cohorts in the Veterans Affairs Health System

Incidental skin malignancies in teledermatology and in-person cohorts in the Veterans Affairs Health System

A Pilot Population-Based Outcomes Study Using a Health Information Exchange (HIE): Demographic Comparison of Groups (P07.047)

Objective: We compare demographics and outcomes between two distinct cohorts recruited from the same stroke population: a cohort tracked using in person (IP) interview and a cohort tracked using HIE and a “virtual” telephone interview. Background Post-stroke outcomes are traditionally determined by longitudinal follow-up with IP interview, which is expensive, time consuming and prone to bias. Alternative follow up methods have yet to be explored, especially for considering a population-based outcomes study. Design/Methods: We ascertained all ischemic stroke cases from within our geographic study population during 2010 using HIE messages from all ER/hospital admissions to any of the 16 hospitals in the region. Potential stroke cases were flagged using a computerized algorithm identifying key words. Cases were approached for inclusion in an IP interview cohort using hot pursuit methodology. Those not approached were considered for the HIE cohort. Demographics and key outcomes were compared between cohorts. Results: During 2010, the HIE received 17,671,258 messages about 1,967,415 unique patients seeking care at the regions hospitals. There were 689 ischemic stroke subjects approached during hospitalization; 516 agreed to participate and 408 completed a 3-month IP interview. The HIE cohort consisted of 581 subjects, 532 still living, of whom 116 refused and 215 completed telephone interviews. Race, gender, payor, baseline modified Rankin score (mRS), discharge/30 day mRS, and 3 month mRS were similar between cohorts. Compared to the HIE cohort, the IP cohort was younger (67 vs. 70 years), required less proxy interview (21% vs. 34%), and were less likely to be cognitively impaired (25% vs. 39%), all p Conclusions: The HIE cohort included participants not represented in the IP cohort. Our next steps include investigating how such biases impact modeling of post-stroke outcomes and looking for differences among refusals in each method. Supported by: NINDS R-01 NS30678, “Hemorrhagic and Ischemic Strokes Among Blacks and Whites”. Disclosure: Dr. Kissela has received personal compensation for activities with Allergan and Medicolegal Review. Dr. Kissela has received research support from NexStim. Dr. Alwell has nothing to disclose. Dr. Khoury has nothing to disclose. Dr. Moomaw has nothing to disclose. Dr. Embi has nothing to disclose. Dr. Rademacher has nothing to disclose. Dr. Lindsell has nothing to disclose. Dr. Woo has nothing to disclose. Dr. Flaherty has received personal compensation for activities with Boehringer Ingelheim Pharmaceuticals, Inc. Dr. Flaherty has received research support from NINDS and Novo Nordisk. Dr. Khatri has received personal compensation for activities with law offices as an expert witness. Dr. Khatri has received research support from Genentech, Inc. and Penumbra, Inc. Dr. Adeoye has received personal compensation for activities with EKR Therapeutics for Speaker9s Bureau and consultant services. Dr. Ferioli has nothing to disclose. Dr. Kleindorfer has received personal compensation for activities with Genentech, Inc. and Boehringer Ingelheim Pharmaceuticals, Inc. as a speaker and participant on an advisory board.

Comparison of Throughput Times for Limited English Proficiency Patient Visits in the Emergency Department Between Different Interpreter Modalities

Appropriate interpretation is imperative for families with limited English proficiency (LEP). We compared throughput times for ED visits involving families with LEP based on type of interpretation provided: in-person interpretation, remote telephonic interpretation or bilingual providers. This study is a secondary analysis of a prospective study of caretaker satisfaction with different interpreter modalities. We queried the medical record for event time stamps, clinical factors and disposition. The in-person cohort (116 min) had a significantly shorter total throughput time than telephonic (141 min) and bilingual provider (153 min) cohorts (P < 0.0001), due to a difference in time seen by provider to disposition. Time seen by provider to disposition remained statistically significantly shorter for the in-person cohort when compared to telephonic interpretation when controlling for potential confounders such as admission rate (P = 0.006). In-person interpretation significantly decreased ED throughput times and may be an important consideration in the choice of interpreter modality.