Electronic consultations (E-consults) and their outcomes: a systematic review

OBJECTIVE: Electronic consultations (e-consults) are clinician-to-clinician communications that may obviate face-to-face specialist visits. E-consult programs have spread within the US and internationally despite limited data on outcomes. We conducted a systematic review of the recent peer-reviewed literature on the effect of e-consults on access, cost, quality, and patient and clinician experience and identified the gaps in existing research on these outcomes. MATERIALS AND METHODS: We searched 4 databases for empirical studies published between 1/1/2015 and 2/28/2019 that reported on one or more outcomes of interest. Two investigators reviewed titles and abstracts. One investigator abstracted information from each relevant article, and another confirmed the abstraction. We applied the GRADE criteria for the strength of evidence for each outcome. RESULTS: We found only modest empirical evidence for effectiveness of e-consults on important outcomes. Most studies are observational and within a single health care system, and comprehensive assessments are lacking. For those outcomes that have been reported, findings are generally positive, with mixed results for clinician experience. These findings reassure but also raise concern for publication bias. CONCLUSION: Despite stakeholder enthusiasm and encouraging results in the literature to date, more rigorous study designs applied across all outcomes are needed. Policy makers need to know what benefits may be expected in what contexts, so they can define appropriate measures of success and determine how to achieve them. Informatics Association 2019. This work is written by US Government employees and is in the public domain in the US

Familial idiopathic normal pressure hydrocephalus

Idiopathic normal pressure hydrocephalus (iNPH) is a late-onset surgically alleviated, progressive disease. We characterize a potential familial subgroup of iNPH in a nation-wide Finnish cohort of 375 shunt-operated iNPH-patients. The patients were questionnaired and phone-interviewed, whether they have relatives with either diagnosed iNPH or disease-related symptomatology. Then pedigrees of all families with more than one iNPH-case were drawn. Eighteen patients (4.8%) from 12 separate pedigrees had at least one shunt-operated relative whereas 42 patients (11%) had relatives with two or more triad symptoms. According to multivariate logistic regression analysis, familial iNPH-patients had up to 3-fold risk of clinical dementia compared to sporadic iNPH patients. This risk was independent from diagnosed Alzheimer's disease and APOE epsilon 4 genotype. This study describes a familial entity of iNPH offering a novel approach to discover the potential genetic characteristics of iNPH. Discovered pedigrees offer an intriguing opportunity to conduct longitudinal studies targeting potential preclinical signs of iNPH. (C) 2016 Elsevier B.V. All rights reserved.Peer reviewe

The unruptured intracranial aneurysm treatment score A multidisciplinary consensus

Objective: We endeavored to develop an unruptured intracranial aneurysm (UIA) treatment score (UIATS) model that includes and quantifies key factors involved in clinical decision-making in the management of UIAs and to assess agreement for this model among specialists in UIA management and research. Methods: An international multidisciplinary (neurosurgery, neuroradiology, neurology, clinical epidemiology) group of 69 specialists was convened to develop and validate the UIATS model using a Delphi consensus. For internal (39 panel members involved in identification of relevant features) and external validation (30 independent external reviewers), 30 selected UIA cases were used to analyze agreement with UIATS management recommendations based on a 5-point Likert scale (5 indicating strong agreement). Interrater agreement (IRA) was assessed with standardized coefficients of dispersion (v(r)*) (v(r)* 5 0 indicating excellent agreement and v(r)* = 1 indicating poor agreement). Results: The UIATS accounts for 29 key factors in UIA management. Agreement with UIATS (mean Likert scores) was 4.2 (95% confidence interval [CI] 4.1-4.3) per reviewer for both reviewer cohorts; agreement per case was 4.3 (95% CI 4.1-4.4) for panel members and 4.5 (95% CI 4.3-4.6) for external reviewers (p = 0.017). Mean Likert scores were 4.2 (95% CI 4.1-4.3) for interventional reviewers (n = 56) and 4.1 (95% CI 3.9-4.4) for noninterventional reviewers (n = 12) (p = 0.290). Overall IRA (v(r)*) for both cohorts was 0.026 (95% CI 0.019-0.033). Conclusions: This novel UIA decision guidance study captures an excellent consensus among highly informed individuals on UIA management, irrespective of their underlying specialty. Clinicians can use the UIATS as a comprehensive mechanism for indicating how a large group of specialists might manage an individual patient with a UIA.Peer reviewe

High Risk Population Isolate Reveals Low Frequency Variants Predisposing to Intracranial Aneurysms

Peer reviewe

Environmental epidemiology and public health in rural Ecuador

The purpose of the present research was to determine the frequency and risk factors for common causes of morbidity in Santa Ana, Ecuador. Initial studies on intestinal parasitism identified several host-environment-related risk factors for Entamoeba histolytica/dispar, Ascaris lumbricoides , and Giardia lamblia among children. A survey of 200 households revealed 65.6% of children were infected with these parasites. In the final multivariate logistic model, risk factors (p \u3c 0.05) for parasitic infections included low socioeconomic status, infrequent antiparasitic treatment, not adding chlorine to drinking water, and children not washing their hands before eating. During the course of the parasite study, women were often observed cooking indoors with open wood fires. Based on a high prevalence of respiratory disease in children, a cross sectional study was conducted to examine exposure-response relationships between indoor air pollution from biomass combustion and respiratory health. Four groups of 20 households each were selected based on the relative amount of liquid petroleum gas and biomass fuel used for cooking. An adult living in each household was asked a series of questions relating to the household environment, history of infant mortality, and history of respiratory symptoms for each household member. Pulmonary function tests were conducted on 77 children (\u3c 16 years) and 135 adults (≤ 16 years). A positive exposure-response relationship was found for both history of infant mortality (p = 0.02) and increasing number of infant deaths (p = 0.01) with increasing use of biomass fuel. A similar exposure-response relationship was found for a history of respiratory symptoms among children. In addition, children living in homes that used biomass fuel for cooking had a lower forced vital capacity (FVC) (p \u3c 0.05) and forced expiratory volume in one second (FEV1) (p \u3c 0.10) when compared with children living in homes that cooked with liquid petroleum gas only, though no difference in pulmonary function was observed among adults in different cooking categories. The results of these studies add to our understanding of the epidemiology of common diseases in the developing world and are important for designing effective public health campaigns in Santa Ana

Positron emission tomography examination of cerebral blood flow and glucose metabolism in young CADASIL patients

Background and Purpose - CADASIL causes repeated ischemic strokes leading to subcortical vascular dementia. The purpose of this study was to assess whether cerebral blood flow (CBF) and regional cerebral metabolic rates of glucose (rCMR(gluc)) in CADASIL patients are affected in early adulthood. Methods - CBF and rCMR(gluc) were examined with positron emission tomography in correlation with magnetic resonance imaging (MRI) in 14 adult ( 19 to 41 years) CADASIL patients with the Notch3 R133C mutation. Seven patients had experienced transient ischemic attack and 3 had experienced greater than or equal to1 strokes. Results - The mean CBF in the CADASIL patients was significantly lower in both frontal (P = 0.019) and occipital (P = 0.009) white matter (WM) than those in the controls. CBF decreased significantly with increased severity of the disease. The patients had lower mean rCMR(gluc) values than the controls, although differences were not statistically significant. Sum scores of semiquantitative MRI rating scale (Scheltens) correlated significantly with WM CBF but not with rCMR(gluc). Conclusions - In CADASIL, there is an early and significant decrease in the CBF of WM associated with simultaneous MRI changes. These are obviously caused by the arteriopathy in long penetrating arteries and indicate early tissue damage, also expressed as impaired rCMR(gluc) in the WM.Peer reviewe

Electronic consultations and economies of scale: a qualitative study of clinician perspectives on scaling up e-consult delivery

OBJECTIVE: To explore Veterans Health Administration clinicians\u27 perspectives on the idea of redesigning electronic consultation (e-consult) delivery in line with a hub-and-spoke (centralized) model. MATERIALS AND METHODS: We conducted a qualitative study in VA New England Healthcare System (VISN 1). Semi-structured phone interviews were conducted with 35 primary care providers and 38 specialty care providers, including 13 clinical leaders, at 6 VISN 1 sites varying in size, specialist availability, and e-consult volume. Interviews included exploration of the hub-and-spoke (centralized) e-consult model as a system redesign option. Qualitative content analysis procedures were applied to identify and describe salient categories. RESULTS: Participants saw several potential benefits to scaling up e-consult delivery from a decentralized model to a hub-and-spoke model, including expanded access to specialist expertise and increased timeliness of e-consult responses. Concerns included differences in resource availability and management styles between sites, anticipated disruption to working relationships, lack of incentives for central e-consultants, dedicated staff\u27s burnout and fatigue, technological challenges, and lack of motivation for change. DISCUSSION: Based on a case study from one of the largest integrated healthcare systems in the United States, our work identifies novel concerns and offers insights for healthcare organizations contemplating a scale-up of their e-consult systems. CONCLUSIONS: Scaling up e-consults in line with the hub-and-spoke model may help pave the way for a centralized and efficient approach to care delivery, but the success of this transformation will depend on healthcare systems\u27 ability to evaluate and address barriers to leveraging economies of scale for e-consults. Informatics Association 2021. This work is written by US Government employees and is in the public domain in the US