Telemedicine and home care: controversies and opportunities

Summary This review focuses on the prospects, and possible drawbacks, of a new innovative instrument of care known as "home telehealth", "telecare" or "telemedicine". The main results from utilising telemedicine in respiratory diseases (asthma and chronic obstructive pulmonary disease (COPD) as the illustrative conditions) are presented. A principal goal of telemedicine is to improve access to healthcare services. During this process, savings in time and travel costs should be achieved, thereby rationalising access to medical care. The field of telemedicine is relatively new and expanding. In order to establish evidencebased guidelines for the design and implementation of disease management plans that employ telemedicine, further research is required. Telemedicine is not simply "technology" but an innovative medical approach (based more on a dedicated healthcare team than on high-tech instruments) that will help the medical team to care for patients and their families. In the future, it is hoped that telemedicine will form a valuable part of the disease management process, because, when used intelligently, home telehealth should supplement conventional delivery techniques and not replace them

The Walsh family resilience questionnaire: The Italian version

Background: Resilience focuses on strength under stress, in the context of adversity. Walsh\u2019s theoretical model identifies relational processes that allow families to tackle and overcome critical situations, dividing them into three domains of family function. The aim of this study was to assess resilience in families of patients with a chronic disease by adapting and validating the Italian version of the Walsh Family Resilience Questionnaire (Walsh-IT). Patients and methods: An Italian adult sample of 421 participants (patients and relatives) was collected with the aim to assess the reliability and validity of the Walsh-IT. Concurrent validity was carried out by comparing this instrument with the Family Adaptability and Cohesion Evaluation Scale III (FACES III) administered at the same time as the Walsh-IT. Results: Reliability showed high correlation between repeated measurements. The alpha coefficient was 0.946. Both parallel analysis and minimum average partial criteria suggested that the best number of domains is equal to 3, explaining 50.4% of the total variance. Based on the results obtained from the Rasch analysis, items 10, 11, 16, 22, and 23 have been removed resulting in a short-form questionnaire (Walsh-IT-R) of 26 items with three domains: shared beliefs and support (SBS, \u3b1=0.928); family organization and interaction (FOI, \u3b1=0.863); and utilization of social resources (USR, \u3b1=0.567). The total score of the Walsh-IT-R was strongly correlated with the total score of FACES III Real Family Scale (r=0.68; p,0.0001). Conclusion: Results support that the Walsh-IT-R is a valid instrument for the assessment of family resilience in Italy when contending with the challenges of chronic disease. It could be used in pre- and post-assessment in practice effectiveness research, offering a profile of family resilience processes at the start and end of interventions and follow-up

Brisk walking can be a maximal effort in heart failure patients: a comparison of cardiopulmonary exercise and 6 min walking test cardiorespiratory data

Aims Cardiopulmonary exercise test (CPET) and 6 min walking test (6MWT) are frequently used in heart failure (HF). CPET is a maximal exercise, whereas 6MWT is a self-selected constant load test usually considered a submaximal, and therefore safer, exercise, but this has not been tested previously. The aim of this study was to compare the cardiorespiratory parameters collected during CPET and 6MWT in a large group of healthy subjects and patients with HF of different severity.Methods and results Subjects performed a standard maximal CPET and a 6MWT wearing a portable device allowing breath-by-breath measurement of cardiorespiratory parameters. HF patients were grouped according to their CPET peak oxygen uptake (peak(V) over-dotO(2)). One hundred and fifty-five subjects were enrolled, of whom 40 were healthy (59 +/- 8 years; male 67%) and 115 were HF patients (69 +/- 10 years; male 80%; left ventricular ejection fraction 34.6 +/- 12.0%). CPET peak(V) over-dotO(2) was 13.5 +/- 3.5 ml/kg/min in HF patients and 28.1 +/- 7.4 mL/kg/min in healthy subjects (P < 0.001). 6MWT-(V) over-dotO(2) was 98 +/- 20% of the CPET peak(V) over-dotO(2) values in HF patients, while 72 +/- 20% in healthy subjects (P < 0.001). 6MWT-(V) over-dot was >110% of CPET peak(V) over-dotO(2) in 42% of more severe HF patients (peak(V) over-dotO(2) < 12 mL/kg/min). Similar results have been found for ventilation and heart rate. Of note, the slope of the relationship between (V) over-dotO(2) at 6MWT, reported as a percentage of CPET peak(V) over-dotO(2) vs. 6MWT (V) over-dotO(2) reported as the absolute value, progressively increased as exercise limitation did.Conclusions In conclusion, the last minute of 6MWT must be perceived as a maximal or even supramaximal exercise activity in patients with more severe HF. Our findings should influence the safety procedures needed for the 6MWT in HF

Methodological issues on the use of administrative data in healthcare research: the case of heart failure hospitalizations in Lombardy region, 2000 to 2012

BACKGROUND: Administrative data are increasingly used in healthcare research. However, in order to avoid biases, their use requires careful study planning. This paper describes the methodological principles and criteria used in a study on epidemiology, outcomes and process of care of patients hospitalized for heart failure (HF) in the largest Italian Region, from 2000 to 2012. METHODS: Data were extracted from the administrative data warehouse of the healthcare system of Lombardy, Italy. Hospital discharge forms with HF-related diagnosis codes were the basis for identifying HF hospitalizations as clinical events, or episodes. In patients experiencing at least one HF event, hospitalizations for any cause, outpatient services utilization, and drug prescriptions were also analyzed. RESULTS: Seven hundred one thousand, seven hundred one heart failure events involving 371,766 patients were recorded from 2000 to 2012. Once all the healthcare services provided to these patients after the first HF event had been joined together, the study database totalled about 91 million records. Principles, criteria and tips utilized in order to minimize errors and characterize some relevant subgroups are described. CONCLUSIONS: The methodology of this study could represent the basis for future research and could be applied in similar studies concerning epidemiology, trend analysis, and healthcare resources utilization

Teleconsultation service to improve healthcare in rural areas: acceptance, organizational impact and appropriateness

Background: Nowadays, new organisational strategies should be indentified to improve primary care and its link with secondary care in terms of efficacy and timeliness of interventions thus preventing unnecessary hospital accesses and costs saving for the health system. The purpose of this study is to assess the effects of the use of teleconsultation by general practitioners in rural areas. Methods: General practitioners were provided with a teleconsultation service from 2006 to 2008 to obtain a second opinion for cardiac, dermatological and diabetic problems. Access, acceptance, organisational impact, effectiveness and economics data were collected. Clinical and access data were systematically entered in a database while acceptance and organisational data were evaluated through ad hoc questionnaires. Results: There were 957 teleconsultation contacts which resulted in access to health care services for 812 symptomatic patients living in 30 rural communities. Through the teleconsultation service, 48 general practitioners improved the appropriateness of primary care and the integration with secondary care. In fact, the level of concordance between intentions and consultations for cardiac problems was equal to 9%, in 86% of the cases the service entailed a saving of resources and in 5% of the cases, it improved the timeliness. 95% of the GPs considered the overall quality positively. For a future routine use of this service, trust in specialists, duration and workload of teleconsultations and reimbursement should be taken into account. Conclusions: Managerial and policy implications emerged mainly related to the support to GPs in the provision of high quality primary care and decision-making processes in promoting similar services

COVID-19 teleassistance and teleconsultation: a matched case-control study (MIRATO project, Lombardy, Italy)

BackgroundDuring the COVID-19 pandemic, telemedicine has been recognised as a powerful modality to shorten the length of hospital stay and to free up beds for the sicker patients. Lombardy, and in particular the areas of Bergamo, Brescia, and Milan, was one of the regions in Europe most hit by the COVID-19 pandemic. The primary aim of the MIRATO project was to compare the incidence of severe events (hospital readmissions and mortality) in the first three months after discharge between COVID-19 patients followed by a Home-Based Teleassistance and Teleconsultation (HBTT group) program and those discharged home without Telemedicine support (non-HBTT group).MethodsThe study was designed as a matched case-control study. The non-HBTT patients were matched with the HBTT patients for sex, age, presence of COVID-19 pneumonia and number of comorbidities. After discharge, the HBTT group underwent a telecare nursing and specialist teleconsultation program at home for three months, including monitoring of vital signs and symptoms. Further, in this group we analysed clinical data, patients' satisfaction with the program, and quality of life.ResultsFour hundred twenty-two patients per group were identified for comparison. The median age in both groups was 70 ± 11 years (62% males). One or more comorbidities were present in 86% of the HBTT patients and 89% in the non-HBTT group (p = ns). The total number of severe events was 17 (14 hospitalizations and 3 deaths) in the HBTT group and 40 (26 hospitalizations and 16 deaths) in the non-HBTT group (p = 0.0007). The risk of hospital readmission or death after hospital discharge was significantly lower in HBTT patients (Log-rank Test p = 0.0002). In the HBTT group, during the 3-month follow-up, 5,355 teleassistance contacts (13 ± 4 per patient) were performed. The number of patients with one or more symptoms declined significantly: from 338 (78%) to 183 (45%) (p < 0.00001). Both the physical (ΔPCS12: 5.9 ± 11.4) component and the mental (ΔMCS12: 4.4 ± 12.7) component of SF-12 improved significantly (p < 0.0001). Patient satisfaction with the program was very high in all participants.ConclusionsCompared to usual care, an HBTT program can reduce severe events (hospital admissions/mortality) at 3-months from discharge and improve symptoms and quality of life.Clinical trial registrationwww.ClinicalTrials.gov, NCT04898179

Cardiac Prevention and Rehabilitation “3.0”: From acute to chronic phase. Position Paper of the ltalian Association for Cardiovascular Prevention and Rehabilitation (GICR-IACPR)

Cardiac rehabilitation (CR) is the subspecialty of clinical cardiology dedicated to the treatment of cardiac patients, early and in the long term after an acute event. The aim of CR is to improve both quality of life and prognosis through prognostic stratification, clinical stabilization and optimization of therapy (pharmacological and non), management of comorbidities, treatment of disability, as well as through the provision and reinforcement of secondary prevention interventions and maintenaince of adherence to treatment. The mission of CR has changed over time. Once centered on the acute phase, aimed primarily at short-term survival, the healthcare of cardiac patients now increasingly involves the chronic phase where the challenge is to guarantee continuity and quality of care in the medium and long-term. The aim of the present position paper is to provide the state-of-the-art of CR in Italy, discussing its trengths and weaknesses as well as future perspectives