Richard Wootton

Twenty years of telemedicine in chronic disease management – an evidence synthesis

A literature review was conducted to obtain a high-level view of the value of telemedicine in the management of five common chronic diseases (asthma, COPD, diabetes, heart failure, hypertension). A total of 141 randomised controlled trials (RCTs) was identified, in which 148 telemedicine interventions of various kinds had been tested in a total of 37,695 patients. The value of each intervention was categorised in terms of the outcomes specified by the investigators in that trial, i.e. no attempt was made to extract a common outcome from all studies, as would be required for a conventional meta-analysis. Summarizing the value of these interventions shows, first, that most studies have reported positive effects (n = 108), and almost none have reported negative effects (n = 2). This suggests publication bias. Second, there were no significant differences between the chronic diseases, i.e. telemedicine seems equally effective (or ineffective) in the diseases studied. Third, most studies have been relatively short-term (median duration 6 months). It seems unlikely that in a chronic disease, any intervention can have much effect unless applied for a long period. Finally, there have been very few studies of cost-effectiveness. Thus the evidence base for the value of telemedicine in managing chronic diseases is on the whole weak and contradictory.

Multicentre randomised control trial comparing real time teledermatology with conventional outpatient dermatological care : societal cost-benefit analysis

Abstract Objectives: Comparison of real time teledermatology with outpatient dermatology in terms of clinical outcomes, cost-benefits, and patient reattendance Design: Randomised controlled trial with a minimum follow up of three months. Setting: Four health centres (two urban, two rural) and two regional hospitals Subjects: 204 general practice patients requiring referral to dermatology services; 102 were randomised to teledermatology consultation and 102 to traditional outpatient consultation. Main outcome measures: Reported clinical outcome of initial consultation, primary care and outpatient reattendance data, and cost-benefit analysis of both methods of delivering care. Results: No major differences were found in the reported clinical outcomes of teledermatology and conventional dermatology. Of patients randomised to teledermatology, 55 (54%) were managed within primary care and 47 (46%) required at least one hospital appointment. Of patients randomised to the conventional hospital outpatient consultation, 46 (45%) required at least one further hospital appointment, 15 (15%) required general practice review, and 40 (39%) no follow up visits. Clinical records showed that 42 (41%) patients seen by teledermatology attended subsequent hospital appointments compared with 41 (40%) patients seen conventionally. The net societal cost of the initial consultation was £132.10 per patient for teledermatology and £48.73 for conventional consultation. Sensitivity analysis revealed that if each health centre had allocated one morning session a week to teledermatology and the average round trip to hospital had been 78 km instead of 26 km, the costs of the two methods of care would have been equal. Conclusions: Real time teledermatology was clinically feasible but not cost effective compared with conventional dermatological outpatient care. However, if the equipment were purchased at current prices and the travelling distances greater, teledermatology would be a cost effective alternative to conventional care

Selective Retention of VLDL, IDL, and LDL in the Arterial Intima of Genetically Hyperlipidemic Rabbits In Vivo Molecular Size as a Determinant of Fractional Loss From the Intima–Inner Media

To explore possible mechanisms whereby the triglyceride-rich lipoproteins IDL and VLDL may promote atherosclerosis, fractional loss of these lipoproteins from the intima-inner media was measured in vivo in genetically hyperlipidemic rabbits of the St Thomass Hospital strain and compared with the fractional loss of LDL, HDL, and albumin. These rabbits exhibit elevated plasma levels of VLDL, IDL, and LDL. In each rabbit, two aliquots of the same macromolecule, one iodinated with 125I and the other with 131I, respectively, were injected intravenously on average 24 and 3 hours, respectively, before removal of the aortic intima-inner media. The fractional loss from the intima-inner media of newly entered macromolecules was then calculated. The average fractional losses for VLDL, IDL, LDL, HDL, and albumin in lesioned aortic arches were 0.1%/h (n = 4), -0.2%/h (n = 3), 1.8%/h (n = 4), 11.4%/h (n = 3), and 26.3%/h (n = 1), respectively; in nonlesioned aortic arches fractional losses for IDL, LDL, HDL, and albumin were 1.7%/h (n = 1), 0.6%/h (n = 2), 14.6%/h (n = 3), and 25.9%/h (n = 3). In both lesioned and nonlesioned aortic arches, the logarithms of these fractional loss values were inversely and linearly dependent on the diameter of the macromolecules (R2 = .57, P = .001 and R2 = .84, P < .001), as determined from electron photomicrographs of negatively stained lipoproteins. These results suggest that after uptake into the arterial intima, VLDL and IDL as well as LDL are selectively retained in comparison with HDL and albumin.

Teledermatology: a review

Teledermatology holds great potential for revolutionizing the delivery of dermatology services, providing equitable service to remote areas and allowing primary care physicians to refer patients to dermatology centres of excellence at a distance. However, before its routine application as a service tool, its reliability, accuracy and cost‐effectiveness need to be verified by rigorous evaluation. Teledermatology can be applied in one of two ways: it may be conducted in real‐time, utilizing videoconferencing equipment, or by store‐and‐forward methods, when transmitted digital images or photographs are submitted with a clinical history. While there is a considerable range of reported accuracy and reliability, evidence suggests that teledermatology will become increasingly utilized and incorporated into more conventional dermatology service delivery systems. Studies to date have generally found that real‐time dermatology is likely to allow greater clinical information to be obtained from the patient. This may result in fewer patients requiring conventional consultations, but it is generally more time‐consuming and costly to the health service provider. It is often favoured by the patient because of the instantaneous nature of the diagnosis and management regimen for the condition, and it has educational value to the primary care physician. Store‐and‐forward systems of teledermatology often give high levels of diagnostic accuracy, and are cheaper and more convenient for the health care provider, but lack the immediacy of patient contact with the dermatologist, and involve a delay in obtaining the diagnosis and advice on management. It is increasingly likely that teledermatology will prove to be a significant tool in the provision of dermatology services in the future. These services will probably be provided by store‐and‐forward digital image systems, with real‐time videoconferencing being used for case conferences and education. However, much more research is needed into the outcomes and limitations of such a service and its effect on waiting lists, as well as possible cost benefits for patients, primary health care professionals and dermatology departments.

Comparison of teleconsultations and face-to-face consultations: preliminary results of a United Kingdom multicentre teledermatology study.

The objective of this multicentre study was to undertake a systematic comparison of face‐to‐face consultations and teleconsultations performed using low‐cost videoconferencing equipment. One hundred and twenty‐six patients were enrolled by their general practitioners across three sites. Each patient underwent a teleconsultation with a distant dermatologist followed by a traditional face‐to‐face consultation with a dermatologist. The main outcome measures were diagnostic concordance rates, management plans and patient and doctor satisfaction. One hundred and fifty‐five diagnoses were identified by the face‐to‐face consultations from the sample of 126 patients. Identical diagnoses were recorded from both types of consultation in 59% of cases. Teledermatology consultations missed a secondary diagnosis in 6% of cases and were unable to make a useful diagnosis in 11% of cases. Wrong diagnoses were made by the teledermatologist in 4% of cases. Dermatologists were able to make a definitive diagnosis by face‐to‐face consultations in significantly more cases than by teleconsultations (P = 0.001). Where both types of consultation resulted in a single diagnosis there was a high level of agreement (κ = 0.96, lower 95% confidence limit 0.91–1.00). Overall follow‐up rates from both types of consultation were almost identical. Fifty per cent of patients seen could have been managed using a single videoconferenced teleconsultation without any requirement for further specialist intervention. Patients reported high levels of satisfaction with the teleconsultations. General practitioners reported that 75% of the teleconsultations were of educational benefit. This study illustrates the potential of telemedicine to diagnose and manage dermatology cases referred from primary care. Once the problem of image quality has been addressed, further studies will be required to investigate the cost‐effectiveness of a teledermatology service and the potential consequences for the provision of dermatological services in the U.K.

Adoption of telemedicine: from pilot stage to routine delivery

BackgroundToday there is much debate about why telemedicine has stalled. Teleradiology is the only widespread telemedicine application. Other telemedicine applications appear to be promising candidates for widespread use, but they remain in the early adoption stage. The objective of this debate paper is to achieve a better understanding of the adoption of telemedicine, to assist those trying to move applications from pilot stage to routine delivery.DiscussionWe have investigated the reasons why telemedicine has stalled by focusing on two, high-level topics: 1) the process of adoption of telemedicine in comparison with other technologies; and 2) the factors involved in the widespread adoption of telemedicine. For each topic, we have formulated hypotheses. First, the advantages for users are the crucial determinant of the speed of adoption of technology in healthcare. Second, the adoption of telemedicine is similar to that of other health technologies and follows an S-shaped logistic growth curve. Third, evidence of cost-effectiveness is a necessary but not sufficient condition for the widespread adoption of telemedicine. Fourth, personal incentives for the health professionals involved in service provision are needed before the widespread adoption of telemedicine will occur.SummaryThe widespread adoption of telemedicine is a major -- and still underdeveloped -- challenge that needs to be strengthened through new research directions. We have formulated four hypotheses, which are all susceptible to experimental verification. In particular, we believe that data about the adoption of telemedicine should be collected from applications implemented on a large-scale, to test the assumption that the adoption of telemedicine follows an S-shaped growth curve. This will lead to a better understanding of the process, which will in turn accelerate the adoption of new telemedicine applications in future. Research is also required to identify suitable financial and professional incentives for potential telemedicine users and understand their importance for widespread adoption.

Quantitative studies of ver low densit lipoprotein: conversion to low densit lipoprotein in normal controls and primar hperlipidaemic states and the role of direct secretion of low densit lipoprotein in heterozgous familial hpercholesterolaemia

Abstract. Autologous 131I‐labelled ver low densit lipoprotein (VLDL) and 125I‐labelled low densit lipoprotein (LDL) were injected into seven normal subjects and twent‐eight geneticall classified hperlipidaemic patients to quantitate lipoprotein interconver‐sion. The apoprotein B specific activit‐time curves for VLDL and intermediate densit lipoprotein (IDL, densit = 1 006–1019 g/ml) intersected at or before the IDL‐B maximum in thirt‐one studies (five normal controls and twent‐six hperlipidaemic subjects) impling that all IDL‐B ma be derived from VLDL‐B. The fractional conversion of VLDL‐B to LDL‐B (densit 1 019‐1 063 g/ml) following a simultaneous spike injection of 131I‐VLDL and 125‐LDL was obtained b deconvolution of the 125I and 131I‐LDL‐B activit curves. 21–65% (mean = 44%) of VLDL‐B was converted to LDL‐B in twent‐three subjects studied. The mean conversion time ranged from 10 to 24 h in ten normotriglceridaemic subjects and from 19 to 42 h (mean = 33 h) in twelve hpertriglceridaemic subjects. In one patient with broad‐β disease the mean conversion time was 55 h. LDL‐B production from VLDL‐B and total LDL‐B snthetic rate were essentiall equal in normal controls and normocholesterolaemic subjects and in the patient with broad‐β disease. But in all six patients with familial hpercholesterolaemia LDL‐B snthetic rate significantl exceeded LDL‐B production from VLDL‐B, indicating direct secretion of 20–72% of LDL‐B at a rate which correlates positivel with plasma LDL concentration. Three of five patients with familial combined hperlipidaemia showed a lesser but nevertheless significant direct secretion of LDL‐B.

Patient satisfaction with realtime teledermatology in Northern Ireland

Teledermatology consultations were organized between two health centres and two hospitals in Northern Ireland using low-cost videoconferencing equipment. A prospective study of patient satisfaction was carried out. Following each teleconsultation, patients were asked to complete a questionnaire assessing their satisfaction with the service. Over 22 months, 334 patients were seen by a dermatologist over the video-link, and 292 patients 87 completed the 16-item questionnaire. Patients reported universal satisfaction with the technical aspects of teledermatology. The quality of both the audio and the display was highly acceptable to patients. Personal experiences of the teledermatology consultation were also favourable: 85 felt comfortable using the video-link. The benefits of teledermatology were generally recognized: 88 of patients thought that a teleconsultation could save time. Patients found the teledermatology consultation to be as acceptable as the conventional dermatology consultation. These findings suggest overall patient satisfaction with realtime teledermatology.

Use of telephone and SMS reminders to improve attendance at hospital appointments: a systematic review

Patients failing to attend hospital appointments contribute to inefficient use of resources. We conducted a systematic review of studies providing a reminder to patients by phone, short message service (SMS) or automated phone calls. A PubMed search was conducted to identify articles published after 1999, describing studies of non-attendance at hospital appointments. In addition, we searched the references in the included papers. In total, 29 studies were included in the review. Four had two intervention arms which were treated as independent studies, giving a total of 33 estimates. The papers were analysed by two observers independently. A study quality score was developed and used to weight the data. Weighted means of the absolute and the relative changes in non-attendance were calculated. All studies except one reported a benefit from sending reminders to patients prior to their appointment. The synthesis suggests that the weighted mean relative change in non-attendance was 34% of the baseline non-attendance rate. Automated reminders were less effective than manual phone calls (29% vs 39% of baseline value). There appeared to be no difference in non-attendance rate, whether the reminder was sent the day before the appointment or the week before. Cost and savings were not measured formally in any of the papers, but almost half of them included cost estimates. The average cost of using either SMS, automated phone calls or phone calls was €0.41 per reminder. Although formal evidence of cost-effectiveness is lacking, the implication of the review is that all hospitals should consider using automated reminders to reduce non-attendance at appointments.

Telemedicine : a cautious welcome

Telemedicine is a major new development. Having become technically and economically feasible, it deserves proper investigation. Rushing into equipment purchase, however, is almost certain to prove counterproductive. Face to face contact is fundamental to health care and enthusiasts of telemedicine should recognise that it is not as good as the real thing (and unlikely ever to be). However, constraints on time and resources will make face to face consultation increasingly expensive, and telemedicine has the potential to produce major efficiencies in the diagnostic process. The goal of current research is therefore to marry medicine with technology, capitalising on the advantages of telemedicine and producing a robust system that delivers an acceptable service at an appropriate price.