Brian A McCrossan

Remote Diagnosis of Congenital Heart Disease: The Impact of Telemedicine

Objectives To determine the accuracy of remote diagnosis of congenital heart disease (CHD) by real-time transmission of echocardiographic images via integrated services digital network (ISDN) lines, to assess the impact on patient management and examine cost implications. Design Prospective comparison of echocardiograms on infants with suspected significant CHD performed as follows: (1) hands-on evaluation and echocardiogram by a paediatrician at a district general hospital (DGH) followed by (2) transmission of the echocardiogram via ISDN 6 with guidance from a paediatric cardiologist and finally (3) hands-on evaluation and echocardiogram by a paediatric cardiologist. The economic analysis compares the cost of patient care associated with the telemedicine service with a hypothetical control group. Setting Neonatal units of three DGH and a UK regional paediatric cardiology unit. Results Echocardiograms were transmitted on 124 infants. In five cases scans were inadequate for diagnosis. Of the remaining 119 tele-echocardiograms, a follow-up echocardiogram was performed on 109/119 (92%). Major CHD was diagnosed in 39/109 infants (36%) and minor CHD in 45 (41%). The tele-echo diagnosis was accurate in 96% of cases (κ=0.89). Unnecessary transfer to the regional unit was avoided in 93/124 patients (75%). Despite relatively high implementation costs, telemedicine care was substantially cheaper than standard care. Each DGH potentially saved money by utilising the telemedicine service (mean saving: £728/patient). Conclusions CHD is accurately diagnosed by realtime transmission of echocardiograms performed by paediatricians under live guidance and interpretation by a paediatric cardiologist. Remote diagnosis and exclusion of CHD affects patient management and may be cost saving.

Diagnosis of congenital heart disease in neonates by videoconferencing: an eight-year experience.

Summary Over an eight-year period, echocardiograms were transmitted by ISDN at 384 kbit/s for a total of 132 patients suspected of having congenital heart disease (CHD). Five transmitted scans were inadequate. Hands-on echocardiograms were performed subsequently on 116 of the remaining 127 cases (91%). Major CHD was diagnosed in 42 of the 116 infants (36%) and minor CHD in 49 (42%). The telemedicine diagnosis was accurate in 97% of the cases (kappa = 0.90). There were four diagnostic errors. Transfer to the regional unit was avoided in 95 patients (72%). The present study shows that high diagnostic accuracy is possible using a telemedicine link to transmit images obtained with the assistance of real-time guidance by a paediatric cardiologist. The results also demonstrate the importance of an expert interpreting the echocardiographic images, since the accuracy of diagnosis was considerably improved (the kappa coefficient increased from 0.14 to 0.90).

Assisting the transition from hospital to home for children with major congenital heart disease by telemedicine: A feasibility study and initial results

Parents of children hospitalized with major congenital heart disease often state that the weeks following discharge from hospital are particularly difficult. There is a sudden change from 24-h medical supervision and care to outpatient reviews. Videoconferencing not only gives the family an opportunity to have visual and audio contact with staff but also allows clinicians to visually assess the patient. We have investigated the feasibility of using videoconferencing to provide support for families at home. We also report the early results of a randomized control trial comparing videoconference support with regular telephone support and the current clinic review follow-up.

Down syndrome, achondroplasia and tetralogy of Fallot.

This paper describes a female infant with achondroplasia, Down syndrome and tetralogy of Fallot. Down syndrome and achondroplasia were confirmed by karyotyping and presence of a common fibroblast growth factor receptor 3 mutation (Gly380Arg), respectively. The clinical course was complicated by pulmonary hypoplasia and subsequent intractable respiratory failure secondary to the combination of congenital conditions, which resulted in the patient’s death at 5 months.

Home support for children with complex congenital heart disease using videoconferencing via broadband: initial results

Summary We originally developed a home support service for babies with complex congenital heart disease, in which videoconferencing was delivered via three ISDN lines. We have now investigated the feasibility of using broadband (Internet protocol) transmission instead of ISDN lines. Five patients were enrolled (age range 14–58 days) and 78 videoconferences were conducted over a six-month period. In 70 videoconferences (90%), a successful connection was established at the first attempt. In the last 56 videoconferences a connection bandwidth of 256 kbit/s was consistently achieved. The clinicians opinions of the videoconferences were good. Parental opinions on the videoconferences were very high. There was also a significant reduction in parental anxiety following the video consultations: the median reduction in the STAI score was 6 points (P < 0.05) (n = 78). Home support for infants or children with complex congenital heart disease can be provided successfully by video consultations utilizing home broadband links.

A Cost Analysis of a Remote Home Support Programme for Infants with Major Congenital Heart Disease: Evidence from a Randomized Controlled Trial

A Cost Analysis of a Remote Home Support Programme for Infants with Major Congenital Heart Disease: Evidence from a Randomized Controlled Trial Objective: Paediatric cardiology is a highly centralised subspecialty with patients living often living large distances from the tertiary care centre. A tele homecare programme for infants with major congenital heart disease (CHD) was devised to support patients and families during the stressful and vulnerable period following discharge from hospital. This study aimed to describe the costs and potential savings of a telemedicine home support programme for infants with major congenital heart disease (CHD). Methods: A randomized controlled trial was performed at a UK tertiary paediatric cardiology centre. Infants with major CHD discharged home were randomized to one of three groups: Two intervention groups (Video support and Telephone support) and one control group (standard care). Patients in the two intervention groups received regular, standardised remote consultations. Video support initially provided by ISDN lines and later by a home broadband (IP) connection. The main outcome measure was a comparison of total cost to NHS of participants including cost of study interventions and health service utilisation.

A comparison of ISDN and home broadband transmission in delivering home support for infants with major congenital heart disease

In 2003, the paediatric cardiology department at the Royal Belfast Hospital for Sick Children (RBHSC) piloted home support for infants with major congenital heart disease based on videoconference consultations. The videoconferencing used an ISDN 6 link (3 ISDN lines aggregated to provide a bandwidth of 384 kbit/s) installed in each family’s home. Following the success of this pilot trial, a randomised controlled trial of the home support programme was initiated in 2005 using ISDN 6. During the 2000s, Internet provision in the community accelerated, both in terms of availability and increasing bandwidths. We therefore began pilot tests using an ADSL connection, ultimately switching from ISDN to ADSL transmission for the telecardiology work. The present study compared the quality of remote consultations achieved with the two modalities.

Survey of paediatricians' opinions on a regional paediatric telecardiology service.

The aim of this study is to evaluate consultant general paediatricians’ opinions of a UK paediatric telecardiology service.

Telemedicine in the Diagnosis and Managemnt of Congenital Heart Disease

Several telemedicine applications have become well established in paediatric cardiology but there is potential for improvement in and expansion of existing programmes and opportunities for new applications. This chapter shall discuss why telemedicine has an important role to play in paediatric cardiology, examine current applications from fetus to adult, including the evidence base and suggest what future steps may be taken to promote the use of telemedicine in paediatric cardiology. We shall also consider what equipment and personnel are necessary for successful tele-cardiology. However, before examining the role of telemedicine in paediatric cardiology, it is first important to understand what congenital heart disease is and how it presents to clinicians.

Removal of scatter radiation in paediatric cardiac catheterisation: a randomised controlled clinical trial

OBJECTIVE This study sought to determine if DNA integrity was compromised by ionising radiation from paediatric cardiac catheterisations and if dose optimisation techniques allowed DNA integrity to be maintained. MATERIALS AND METHODS Children were imaged using either: (i) an anti-scatter grid (current departmental protocol), (ii) no anti-scatter grid or, (iii) no anti-scatter grid and a 15 cm air-gap between the child and the x-ray detector. Dose area product and image quality were assessed, lifetime attributable cancer risk estimates were calculated and DNA double-strand breakages quantified using the γH2AX assay. RESULTS Consent was obtained from 70 parents/guardians/children. Image quality was sufficient for each procedure performed. Removal of the anti-scatter grid resulted in dose reductions of 20% (no anti-scatter grid) and 30% (15 cm air-gap), DNA double-strand break reductions of 30% (no anti-scatter grid) and 20% (15 cm air-gap) and a reduction of radiation-induced cancer mortality risk of up to 45%. CONCLUSION Radiation doses received during paediatric cardiac catheterisation procedures resulted in a significant increase in DNA damage while maintaining acceptable image quality and diagnostic efficacy. It is feasible to remove the anti-scatter grid resulting in a reduction in DNA damage to the patient. The γH2AX assay may be used for assessment of dose optimisation strategies in children.