Approaches to Evaluations of Virtual Care in Primary Care

A literature search informed this Environmental Scan and identified 11 evaluations of virtual care in primary care health settings and 7 publications alluding to methods, standards, and guidelines (referred to as evaluation guidance documents in this report) being used in various countries to evaluate virtual care in primary care health settings. The majority of included literature was from Australia, the US, and the UK, with 2 evaluation guidance documents published by the Heart and Stroke Foundation of Canada. Evaluation guidance documents recommended using measurements that assess the effectiveness and quality of clinical care including safety outcomes, time and travel, financial and operational impact, participation, health care utilization, technology experience including feasibility, user satisfaction, and barriers and facilitators or measures of health equity. Evaluation guidance documents specified that the following key decisions and considerations should be integrated into the planning of a virtual care evaluation: refining the scope of virtual care services; selecting an appropriate meaningful comparator; and identifying opportune timing and duration for the evaluation to ensure the evaluation is reflective of real-world practice, allows for adequate measurement of outcomes, and is comprehensive, timely, feasible, non-complex, and non–resource-intensive. Evaluation guidance documents highlighted that evaluations should be systematic, performed regularly, and reflect the stage of virtual care implementation to encompass the specific considerations associated with each stage. Additionally, evaluations should assess individual virtual care sessions and the virtual care program as a whole. Regarding economic components of virtual care evaluations, the evaluation guidance documents noted that costs or savings are not limited to monetary or financial measures but can also be represented with time. Cost analyses such as cost-benefit and cost-utility estimates should be performed with a specific emphasis on selecting an appropriate perspective (e.g., patient or provider), as that influences the benefits, effects, and how the outcome is interpreted. Two identified evaluations assessed economic outcomes through cost analyses in the perspective of the patient and provider. Evidence suggests that, in some circumstances, virtual care may be more cost-effective and reduces the cost per episode and patient expenses (e.g., travel and parking costs) compared to in-person care. However, virtual care may increase the number of individuals treated, which would increase overall health care spending. Four identified evaluations assessed health care utilization. The evidence suggests that virtual care reduces the duration of appointments and may be more time-efficient compared to in-person care. However, it is unclear if virtual care reduces the use of medical resources and the need for follow-up appointments, hospital admissions, and emergency department visits compared to in-person care. Five identified evaluations assessed participation outcomes. Evidence was variable, with some evidence reporting that virtual care reduced attendance (e.g., reduced attendance rates) and other evidence noting improved attendance (e.g., increased completion rate and decreased cancellations and no-show rates) compared to in-person care. Three identified evaluations assessed clinical outcomes in various health contexts. Some evidence suggested that virtual care improves clinical outcomes (e.g., in primary care with integrated mental health services, symptom severity decreased) or has a similar effect on clinical outcomes compared to in-person care (e.g., use of virtual care in depression elicited similar results with in-person care). Three identified evaluations assessed the appropriateness of prescribing. Some studies suggested that virtual care improves appropriateness by increasing guideline-based or guideline-concordant antibiotic management, or elicits no difference with in-person care.

impact of virtual care on relationship centered care: Observations of a family physician

The COVID-19 pandemic propelled many physicians and their patients into an unfamiliar world of virtual care. This presentation is based on the perceptions of a family physician/ teacher/ researcher with 43 years of interest in, and promotion of, a strong doctor-patient relationship. It will describe a protocol that governed how tele-medicine and video-conferencing took place over nearly 18 months in his practice. It will then describe observed positive and negative impacts for the patients, their family members, the physician, and members of the family medicine health care team. Interpretation will be made about what such observations mean for the doctor-patient relationship.

Many people admitted to hospital with a provisional diagnosis of nonserious back pain are subsequently found to have serious pathology as the underlying cause

To determine the proportion of patients admitted to the hospital for back pain who have nonserious back pain, serious spinal, or serious other pathology as their final diagnosis. The proportion of nonserious back pain admissions will be used to plan for future ‘virtual hospital’ admissions. Electronic medical record data between January 2016 and September 2020 from three emergency departments (ED) in Sydney, Australia were used to identify inpatient admissions. SNOMED-CT-AU diagnostic codes were used to select ED patients aged 18 and older with an admitting diagnosis related to nonserious back pain. The inpatient discharge diagnosis was determined from the primary ICD-10-AM codes by two independent clinician-researchers. Inpatient admissions were then analysed by sociodemographic and hospital admission variables. A total of 38.1% of patients admitted with a provisional diagnosis of nonserious back pain were subsequently diagnosed with a specific pathology likely unsuitable for virtual care; 14.2% with a serious spinal pathology (e.g., fracture and infection) and 23.9% a serious pathology beyond the lumbar spine (e.g., pathological fracture and neoplasm). A total of 57% of admissions were identified as nonserious back pain, likely suitable for virtual care. A challenge for implementing virtual care in this setting is screening for patients with serious pathology. Protocols need to be developed to reduce the risk of patients being admitted to virtual hospitals with serious pathology as the cause of their back pain. Key Points• Among admitted patients provisionally diagnosed in ED with non-serious back pain, 38.1% were found to have ‘serious spinal pathologies’ or ‘serious pathologies beyond the lumbar spine’ at discharge.• Spinal fractures were the most common serious spinal pathology, accounting for 9% of all provisional ‘non-serious back pain’ admissions from ED.• 57% of back pain admissions were confirmed to be non-serious back pain and may be suitable to virtual hospital care; the challenge is discriminating these patients from those with serious pathology.

Telehealth for rehabilitation and recovery after stroke: State of the evidence and future directions

Aims: The aim of this rapid review and opinion paper is to present the state of the current evidence and present future directions for telehealth research and clinical service delivery for stroke rehabilitation. Methods: We conducted a rapid review of published trials in the field. We searched Medline using key terms related to stroke rehabilitation and telehealth or virtual care. We also searched clinical trial registers to identify key ongoing trials. Results: The evidence for telehealth to deliver stroke rehabilitation interventions is not strong and is predominantly based on small trials prone to Type 2 error. To move the field forward, we need to progress to trials of implementation that include measures of adoption and reach, as well as effectiveness. We also need to understand which outcome measures can be reliably measured remotely, and/or develop new ones. We present tools to assist with the deployment of telehealth for rehabilitation after stroke. Conclusion: The current, and likely long-term, pandemic means that we cannot wait for stronger evidence before implementing telehealth. As a research and clinical community, we owe it to people living with stroke internationally to investigate the best possible telehealth solutions for providing the highest quality rehabilitation.

How Do Virtual Visits Compare? Parent Satisfaction With Pediatric Diabetes Telehealth During the COVID-19 Pandemic

BackgroundIn response to the COVID-19 pandemic, many countries relaxed restrictions on telemedicine, allowing for a robust transition to virtual visits for routine care. In response, centers rapidly instituted and scaled telemedicine for pediatric diabetes care. Despite numerous center reports on their experience, little is known about parent perspectives on the widespread increase of telemedicine for pediatric diabetes appointments.ObjectiveTo assess parent satisfaction with virtual care for pediatric diabetes during the COVID-19 pandemic.MethodsWe conducted an online, cross-sectional survey of parents of youth with diabetes who receive care at a large, academic diabetes center regarding their perspectives on newly introduced virtual appointments. Parents were surveyed at two time points during the pandemic using a validated scale which was adapted for diabetes. We explored demographic and clinical factors which may influence parental satisfaction.ResultsOverall, parents expressed high levels of satisfaction (>90%) with functional aspects of the visit, though only approximately half (56%) felt the visit was as good as an in-person encounter. Nearly three-quarters (74%) would consider using telemedicine again in the future. Prior use of telemedicine significantly influenced parent satisfaction, suggesting that parent preferences may play a role in continued use of telemedicine in the future. There was no difference in responses across the two timepoints, suggesting high satisfaction early in the pandemic which persisted.ConclusionsIf permissive policies for telemedicine continue, diabetes centers could adopt hybrid in-person and virtual care models, while considering various stakeholder perspectives (providers and patients) and equity in access to virtual care.

COVID-19 in children in NSW, Australia, during the 2021 Delta outbreak: Severity and Disease spectrum

Objective(s): To describe the severity and clinical spectrum of SARS-CoV-2 infection in Australian children during the 2021 Delta outbreak. Design, Setting & Participants: A prospective cohort study of children <16 years with a positive SARS-CoV-2 nucleic acid test cared for by the Sydney Children's Hospital Network (SCHN) virtual and inpatient medical teams between 1 June-31 October 2021. Main outcome measures: Demographic and clinical data from all admitted patients and a random sample of outpatients managed under the SCHN virtual care team were analysed to identify risk factors for admission to hospital. Results: There were 17,474 SARS-CoV-2 infections in children <16 years in NSW during the study period, of whom 11,985 (68.6%) received care coordinated by SCHN. Twenty one percent of children infected with SARS-CoV-2 were asymptomatic. For every 100 SARS-CoV-2 infections in children <16 years, 1.26 (95% CI 1.06 to 1.46) required hospital admission for medical care; while 2.46 (95% CI 2.18 to 2.73) required admission for social reasons only. Risk factors for hospitalisation for medical care included age <6 months, a history of prematurity, age 12 to <16 years, and a history of medical comorbidities (aOR 7.23 [95% CI 2.92 to 19.4]). Of 17,474 infections, 15 children (median age 12.8years) required ICU admission; and 294 children required hospital admission due to social or welfare reasons. Conclusion: The majority of children with SARS-CoV-2 infection (Delta variant) had asymptomatic or mild disease. Hospitalisation was uncommon and occurred most frequently in young infants and adolescents with comorbidities. More children were hospitalised for social reasons than for medical care.

Ushering in a New Era for King’s Conceptual System and Theory of Goal Attainment

The COVID-19 pandemic has ushered in a new era for nurses and healthcare. King’s conceptual framework continues to provide a practical theoretical underpinning for nurse-client interactions in virtual care spaces that are now a pervasive part of the interacting systems framework. The author in this article discusses the current applications and future opportunities for applications of King’s work in practice, education, and research.

Use and impact of virtual primary care on quality and safety: The public's perspectives during the COVID-19 pandemic

Introduction With the onset of Coronavirus disease (COVID-19), primary care has swiftly transitioned from face-to-face to virtual care, yet it remains largely unknown how this has impacted the quality and safety of care. We aim to evaluate patient use of virtual primary care models during COVID-19, including change in uptake, perceived impact on the quality and safety of care and willingness of future use. Methodology An online cross-sectional survey was administered to the public across the United Kingdom, Sweden, Italy and Germany. McNemar tests were conducted to test pre- and post-pandemic differences in uptake for each technology. One-way analysis of variance was conducted to examine patient experience ratings and perceived impacts on healthcare quality and safety across demographic characteristics. Results Respondents (n = 6326) reported an increased use of telephone consultations ( + 6.3%, p < .001), patient-initiated services ( + 1.5%, n = 98, p < 0.001), video consultations ( + 1.4%, p < .001), remote triage ( + 1.3, p < 0.001) and secure messaging systems ( + 0.9%, p = .019). Experience rates using virtual care technologies were higher for men (2.4 ± 1.0 vs. 2.3 ± 0.9, p < .001), those with higher literacy (2.8 ± 1.0 vs. 2.3 ± 0.9, p < .001), and participants from Germany (2.5 ± 0.9, p < .001). Healthcare timeliness and efficiency were the dimensions most often reported as being positively impacted by virtual technologies (60.2%, n = 2793 and 55.7%, n = 2,401, respectively), followed by effectiveness (46.5%, n = 1802), safety (45.5%, n = 1822), patient-centredness (45.2%, n = 45.2) and equity (42.9%, n = 1726). Interest in future use was highest for telephone consultations (55.9%), patient-initiated digital services (56.1%), secure messaging systems (43.4%), online triage (35.1%), video consultations (37.0%) and chat consultations (30.1%), although significant variation was observed between countries and patient characteristics. Discussion Future work must examine the drivers and determinants of positive experiences using remote care to co-create a supportive environment that ensures equitable adoption and use. Comparative analysis between countries and health systems offers the opportunity for policymakers to learn from best practices internationally.