Natalie Bradford

Telemedicine - is the cart being put before the horse?

A large literature base on telemedicine exists, but the evidence base for telemedicine is very limited. There is little practical or useful information to guide clinicians and health policymakers. Telemedicine is often implemented based on limited or no prior formal analysis of its appropriateness to the circumstances, and adoption of telemedicine by clinicians has been slow and patchy. Formal analysis should be conducted before implementation of telemedicine to identify the patients, conditions and settings that it is likely to benefit. Primary studies of telemedicine tend to be of insufficient quality to enable synthesis of formal evidence. Methods typically used to assess effectiveness in medicine are often difficult, expensive or impractical to apply to telemedicine. Formal studies of telemedicine should examine efficacy, effectiveness, economics and clinician preferences. Successful adoption and sustainable integration of telemedicine into routine care could be improved by evidence‐based implementation.

Telemedicine – A bibliometric and content analysis of 17,932 publication records

OBJECTIVES We aimed to provide an up-to-date contemporary bibliometric view of the telemedicine and telehealth literature and a longitudinal analysis of changes in content themes. METHODS Software tools were used to extract and process MEDLINE entries. Frequencies of papers by year of publication and outlet were calculated, ranked, charted and tabulated. Frequency of publication by author was also calculated, ranked and tabulated. The process was repeated for two time periods to examine change: (i) 1970-1995 and (ii) 2009-2013. Content analysis of abstracts was conducted and tag clouds were generated. This visual representation was used to identify key words and prominent themes. RESULTS 17,932 records relating to articles published in 2523 unique outlets were analyzed. In the cumulative literature, 3152 (18%) articles were published in specialist telemedicine journals while most articles (14,780 [82%]) were published in mainstream outlets. This pattern was observed in both epochs. Clinical journals were not highly represented. Over time 46,066 unique authors have contributed to the field, with 21,109 of them publishing in the period 2009-2013. DISCUSSION Telemedicine is a large and growing field with most publication occurring outside of the specialist journals. Content analysis suggested a change of focus from the technical to the clinical between the two epochs. As a healthcare setting, the home also appears to be emergent. CONCLUSION This study updates the findings of previous studies. The emphasis within the literature suggests a move from technical issues to clinical applications and evaluation. The maturity of the field and its accessibility to clinicians and policy makers remains unclear.

The case for home based telehealth in pediatric palliative care: a systematic review

BackgroundOver the last decade technology has rapidly changed the ability to provide home telehealth services. At the same time, pediatric palliative care has developed as a small, but distinct speciality. Understanding the experiences of providing home telehealth services in pediatric palliative care is therefore important.MethodsA literature review was undertaken to identify and critically appraise published work relevant to the area. Studies were identified by searching the electronic databases Medline, CINAHL and Google Scholar. The reference list of each paper was also inspected to identify any further studies.ResultsThere were 33 studies that met the inclusion criteria of which only six were pediatric focussed. Outcome measures included effects on quality of life and anxiety, substitution of home visits, economic factors, barriers, feasibility, acceptability, satisfaction and readiness for telehealth. While studies generally identified benefits of using home telehealth in palliative care, the utilisation of home telehealth programs was limited by numerous challenges.ConclusionResearch in this area is challenging; ethical issues and logistical factors such as recruitment and attrition because of patient death make determining effectiveness of telehealth interventions difficult. Future research in home telehealth for the pediatric palliative care population should focus on the factors that influence acceptance of telehealth applications, including goals of care, access to alternative modes of care, perceived need for care, and comfort with using technology.

Components and Principles of a Pediatric Palliative Care Consultation: Results of a Delphi Study

BACKGROUND Pediatric palliative care is a distinct specialty that requires input from pediatric and palliative medicine specialists to provide comprehensive high-quality care. Consultations undertaken early in a childs illness trajectory, when end-of-life care is not anticipated to be required, enables relationships to be established and may enhance the quality of care provided. OBJECTIVE To define optimal components of an early pediatric palliative care consultation. DESIGN Consensus of an expert group was sought in a five-round Delphi study. SETTING/PARTICIPANTS Based on the literature and existing standards for specialist palliative care, components of an early pediatric palliative care consultation were derived. In rounds 2 and 3, experts from around Australia participated in online surveys to review and prioritize the components and principles. Consensus of survey items was determined by defined criteria. A flowchart was developed in the fourth round and the final round involved review and refinement of the flowchart by the expert group. RESULTS Nineteen experts participated and prioritized 34 components and principles in the first survey round, and 36 statements in the second survey round. There was consensus from all participants that the first priority of a consultation was to establish rapport with the family, and examples of how to achieve this were defined. Other components of a consultation included: establishing the familys understanding of palliative care; symptom management; an emergency plan; discussion of choices for location of care, and a management plan. Components considered suitable to defer to later consultations, or appropriate to address if initiated by family members, included: spiritual or religious issues; discussion around resuscitation and life-sustaining therapies; end-of-life care; and the dying process. CONCLUSION We have provided the first published framework from expert consensus that defines the components and principles of an early pediatric palliative care consultation. This framework will provide guidance for clinical practice as well as being useful for education and research in this area.

Home telehealth and paediatric palliative care: clinician perceptions of what is stopping us?

BackgroundAdvances in technology have made the use of telehealth in the home setting a feasible option for palliative care clinicians to provide clinical care and support. However, despite being widely available and accessible, telehealth has still not been widely adopted either in Australia or internationally. The study aim was to investigate the barriers, enablers and perceived usefulness for an established home telehealth program in paediatric palliative care from the perspective of clinicians.MethodsSemi-structured interviews (n = 10) were undertaken with palliative care clinicians in a tertiary paediatric hospital to identify attitudes to, satisfaction with, and perceived benefits and limitations of, home telehealth in palliative care. Iterative analysis was used to thematically analyse data and identify themes and core concepts from interviews.ResultsFour themes are reported: managing relationships; expectations of clinicians; co-ordination, and the telehealth compromise. Core concepts that emerged from the data were the perceived ability to control clinical encounters in a virtual environment and the need to trust technology. These concepts help explain the telehealth compromise and low utilisation of the home telehealth program.ConclusionsEffective communication between caregivers and clinicians is recognised as a core value of palliative care. Home telehealth has the potential to provide a solution to inequity of access to care, facilitate peer support and maintain continuity of care with families. However, significant limitations and challenges may impede its use. The virtual space creates additional challenges for communication, which clinicians and families may not intuitively understand. For home telehealth to be integrated into routine care, greater understanding of the nature of communication in the virtual space is required.

Humour Sans Frontieres: The Feasibility of Providing Clown Care at a Distance

Clown care has been shown to have health-related benefits and is a well-established part of the routine in many childrens hospitals. However, children who have been admitted to general hospitals or who are being cared for at home cannot usually enjoy visits by Clown Doctors. Therefore, the aim of this work was to investigate whether an existing telemedicine network could be used to improve equity of access to humor for sick children, specifically those who are hospitalized away from the nearest clown-enabled hospital or who are being cared for at home. Using videoconferencing, we conducted regular clown outreach links from The Royal Childrens Hospital in Brisbane, Australia, to children in regional hospitals and to sick children in their homes. Using a program of performance, which was modified for delivery by videoconference, teleclowning was found to be feasible. Further work is required to determine whether the health-related benefits that accrue from in-person clowning are successfully translated to the video-based modality.

Management of febrile neutropenia in pediatric oncology across Queensland, Australia: a retrospective review on variations between locations

Febrile neutropenia (FN) is a common complication in pediatric oncology with intravenous antibiotics being given routinely for decades. This study aimed to compare the management of FN in children in different locations across Queensland, Australia. FN episodes were identified from 4 settings: tertiary oncology outpatient department (OD), tertiary emergency department (ED), regional ward (RW), and regional emergency department (RED) between July 2009 and June 2011. Retrospective data were extracted from medical records, collated, and then analyzed to identify differences in outcomes attributable to location. Sixty-one episodes of FN were reviewed: 5 cases from OD, 28 from ED, 19 from RW, and 5 from RED. Statistically significant differences occurred in the time taken for medical review for cases depending on location of presentation. Patients who presented to the ED or the RW were more likely to be seen within 30 minutes than in other locations (P = .014), and patients who presented to the tertiary hospital in either the OD or ED were more likely to commence antibiotics within 120 minutes of presentation (P = .023). Antibiotics were commenced within 60 minutes (the gold standard) on only 10 occasions. Despite education input emphasizing the importance of early commencement of antibiotics, this study identified that this objective was not met in the majority of cases. Further study is needed to look at reasons for the delay in beginning treatment for pediatric oncology patients in Queensland and what measures may assist with improving the time from presentation with FN to antibiotic administration across all settings.

Home telemedicine for paediatric palliative care

Children with life limiting conditions require intensive, complex management of the physical, psychosocial and spiritual issues that evolve for the child and their family as the focus of care moves from curative treatment to palliation. Optimal palliative care for children can be limited by the lack of health professionals with the necessary skills and experience to confidently and competently manage the care of both the child and the family. The University of Queenslands Centre for Online Health has been working closely with the Paediatric Palliative Care Service (PPCS) at the Royal Childrens Hospital (RCH) in Brisbane, Australia, to investigate the potential of telemedicine for the delivery of specialist support in the home or local community. Research conducted in Queensland has shown how telemedicine can be effectively used to link the specialist paediatric palliative care team into the home of families caring for a child receiving palliative care, regardless of their physical distance from the RCH. This qualitative report describes two case studies, each illustrating the value of home telemedicine for families at this vulnerable and distressing time. This work should provide a useful insight for other specialty disciplines contemplating home telemedicine applications.

Accuracy of dental images for the diagnosis of dental caries and enamel defects in children and adolescents: A systematic review

Aim The aim of this review was to determine if photographic examination and subsequent image analysis provides comparable accuracy to visual inspection for the diagnosis of common dental conditions in children and adolescents. Methods We searched the PubMed database for studies that compared diagnostic accuracy of the two inspection techniques. Studies were screened for inclusion and were assessed for quality and risk of bias using the quality assessment of diagnostic accuracy studies tools. Findings were reported according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA). Findings Sixteen studies met the inclusion criteria. Nine of the included studies evaluated dental caries and eight evaluated enamel defects (one study evaluated both conditions). Conclusions Three studies found image analysis to be superior. For the remaining six studies the diagnostic accuracy was comparable. For enamel defects, three studies found image analysis to be superior, two found visual inspection to be superior and three studies reported comparable diagnostic accuracy. Most studies have found at least comparable results between photographic and visual inspection techniques. However, the wide variation in equipment and personnel used for the collection and interpretation of photographic images made it impossible to generalise the results. It remains unclear exactly how effective store-and-forward teledentistry is for the diagnosis of common dental conditions in children.

Paediatric palliative care by video consultation at home: a cost minimisation analysis.

BackgroundIn the vast state of Queensland, Australia, access to specialist paediatric services are only available in the capital city of Brisbane, and are limited in regional and remote locations. During home-based palliative care, it is not always desirable or practical to move a patient to attend appointments, and so access to care may be even further limited. To address these problems, at the Royal Children’s Hospital (RCH) in Brisbane, a Home Telehealth Program (HTP) has been successfully established to provide palliative care consultations to families throughout Queensland.MethodsA cost minimisation analysis was undertaken to compare the actual costs of the HTP consultations, with the estimated potential costs associated with face-to face-consultations occurring by either i) hospital based consultations in the outpatients department at the RCH, or ii) home visits from the Paediatric Palliative Care Service. The analysis was undertaken from the perspective of the Children’s Health Service. The analysis was based on data from 95 home video consultations which occurred over a two year period, and included costs associated with projected: clinician time and travel; costs reimbursed to families for travel through the Patients Travel Subsidy (PTS) scheme; hospital outpatient clinic costs, project co-ordination and equipment and infrastructure costs. The mean costs per consultation were calculated for each approach.ResultsAir travel (n = 24) significantly affected the results. The mean cost of the HTP intervention was