Nursing home closures and access to post-acute care and long-term care services in rural areas.

PURPOSE: Nursing home closures have raised concerns about access to post-acute care (PAC) and long-term care (LTC) services. We estimate the additional distance rural residents had to travel to access PAC and LTC services because of nursing home closures. METHODS: We identify nursing home closures and the availability of PAC and LTC services in nursing homes, home health agencies, and hospitals with swing beds using the Medicare Provider of Services file (2008-2018). Using distances between ZIP codes, we summarize distances to the closest provider of PAC and LTC services for rural and urban ZIP codes with nursing home closures from 2008 to 2018 and no nursing homes in 2018. FINDINGS: Compared to urban ZIP codes, rural ZIP codes experiencing nursing home closure had higher distances to the closest nursing home providing PAC (6.4 vs. 0.94 miles; p < 0.05) and LTC services (7.2 vs. 1.1 miles; p < 0.05), and these differences remain even after accounting for the availability of home health agencies and hospitals with swing beds. Distances to the closest providers with PAC and LTC services were even higher for rural ZIP codes with no nursing homes in 2018. About 6.1%-15.7% of rural ZIP codes with a nursing home closure or with no nursing homes had no PAC or LTC providers within 25 miles. CONCLUSIONS: Nursing home closures increased distances to nursing homes, home health agencies, and hospitals with swing beds for rural residents. Access to PAC and LTC services is a concern, especially for rural areas with no nursing homes.

Comparison of Treatment Modality Crossovers in Telehealth and In-Person Behavioral Health Treatment in Rural Communities.

Background: Treatment crossovers occur when one mode of treatment is begun and then a different mode of treatment is utilized. Treatment crossovers are frequently examined in randomized controlled trials, but have been rarely noted or quantitatively evaluated in usual care treatment studies. The purpose of this analysis is to examine the extent of modality crossovers during behavioral health treatment. Methods: The nonrandomized, prospective, multisite research design involved two active treatment groups-a telehealth treatment cohort and an in-person treatment cohort. Treatment modality (telehealth or in person) during each encounter was compared overall and across two time periods (pre- and during the COVID-19 pandemic) between the telehealth cohort and the in-person cohort. Results: Overall, modality crossovers were relatively uncommon (6.3%). However, patients in the in-person treatment cohort were more than twice as likely to have an encounter through telehealth (8.5%) than patients in the telehealth treatment cohort were to have an in-person encounter (3.4%) even though they had the same average number of encounters. The occurrence of off-mode encounters was particularly influenced by the onset of the COVID-19 pandemic. Conclusions: In this multisite usual care study comparing telehealth and in-person behavioral health treatment, modality crossovers were more common in the in-person cohort than the telehealth cohort, especially during the COVID-19 pandemic. Because telehealth availability has increased, crossovers are likely to increase in patients receiving multiple encounters for behavioral or chronic conditions and their occurrence should be noted by both researchers and practitioners.

Provider-to-provider telehealth for sepsis patients in a cohort of rural emergency departments.

BACKGROUND: Telehealth has been proposed as one strategy to improve the quality of time-sensitive sepsis care in rural emergency departments (EDs). The purpose of this study was to measure the association between telehealth-supplemented ED (tele-ED) care, health care costs, and clinical outcomes among patients with sepsis in rural EDs. METHODS: Cohort study using Medicare fee-for-service claims data for beneficiaries treated for sepsis in rural EDs between February 1, 2017, and September 30, 2019. Our primary hospital-level analysis used multivariable generalized estimating equations to measure the association between treatment in a tele-ED-capable hospital and 30-day total costs of care. In our supporting secondary analysis, we conducted a propensity-matched analysis of patients who used tele-ED with matched controls from non-tele-ED-capable hospitals. Our primary outcome was total health care payments among index hospitalized patients between the index ED visit and 30 days after hospital discharge, and our secondary outcomes included hospital mortality, hospital length of stay, 90-day mortality, 28-day hospital-free days, and 30-day inpatient readmissions. RESULTS: In our primary analysis, sepsis patients in tele-ED-capable hospitals had 6.7% higher (95% confidence interval [CI] 2.1%-11.5%) total health care costs compared to those in non-tele-ED-capable hospitals. In our propensity-matched patient-level analysis, total health care costs were 23% higher (95% CI 16.5%-30.4%) in tele-ED cases than matched non-tele-ED controls. Clinical outcomes were similar. CONCLUSIONS: Tele-ED capability in a mature rural tele-ED network was not associated with decreased health care costs or improved clinical outcomes. Future work is needed to reduce rural-urban sepsis care disparities and formalize systems of regionalized care.

Telehealth and In-Person Behavioral Health Services in Rural Communities Before and During the COVID-19 Pandemic: Multisite Prospective Cohort Study.

BACKGROUND: The COVID-19 pandemic triggered widespread adjustments across the US health care system. Telehealth use showed a substantial increase in mental health conditions and services due to acute public health emergency (PHE) behavioral health needs on top of long-standing gaps in access to behavioral health services. How health systems that were already providing behavioral telehealth services adjusted services and staffing during this period has not been well documented, particularly in rural areas with chronic shortages of behavioral health providers and services. OBJECTIVE: This study investigates patient and treatment characteristic changes from before the COVID-19 PHE to during the PHE within both telehealth and in-person behavioral health services provided in 95 rural communities across the United States. METHODS: We used a nonrandomized, prospective, multisite research design involving 2 active treatment groups. The telehealth cohort included all patients who initiated telehealth treatment regimens during the data collection period. A comparison group included a cohort of patients who initiated in-person treatment regimen. Patient enrollment occurred on a rolling basis, and data collection was extended for 3 months after treatment initiation for each patient. Chi-square tests compared changes from pre-PHE to PHE time periods within telehealth and in-person treatment cohorts. The dependent measures included patient diagnosis, clinicians providing treatment services, and type of treatment services provided at each encounter. The 4780 patients in the telehealth cohort and the 6457 patients in the in-person cohort had an average of 3.5 encounters during the 3-month follow-up period. RESULTS: The encounters involving anxiety, dissociative, and stress-related disorders in the telehealth cohort increased from 30% (698/2352) in the pre-PHE period to 35% (4632/12,853) in the PHE period (P<.001), and encounters involving substance use disorders in the in-person cohort increased from 11% (468/4249) in the pre-PHE period to 18% (3048/17,047) in the PHE period (P<.001). The encounters involving treatment service codes for alcohol, drug, and medication-assisted therapy in the telehealth cohort increased from 1% (22/2352) in the pre-PHE period to 11% (1470/13,387) in the PHE period (P<.001); likewise, encounters for this type of service in the in-person cohort increased from 0% (0/4249) in the pre-PHE period to 16% (2687/17,047) in the PHE period (P<.001). From the pre-PHE to the PHE period, encounters involving 60-minute psychotherapy in the telehealth cohort increased from 8% (190/2352) to 14% (1802/13,387; P<.001), while encounters involving group therapy in the in-person cohort decreased from 12% (502/4249) to 4% (739/17,047; P<.001). CONCLUSIONS: The COVID-19 pandemic challenged health service providers, and they adjusted the way both telehealth and in-person behavioral therapy services were delivered. Looking forward, future research is needed to explicate the interaction of patient, provider, setting, and intervention factors that influenced the patterns observed as a result of the COVID-19 pandemic.

Change in Drug Use Disorders Identification Test - Consumption (DUDIT-C) with Telehealth Treatment Compared to in-Person Treatment.

Background and Objectives: There is little published evidence for the effectiveness of telehealth in the treatment of substance use disorders. Methods: We analyzed Drug Use Disorders Identification Test - Consumption (DUDIT-C) scores from 360 patients who completed the measure as part of outpatient behavioral health treatment at rural clinic sites. Some patients received in-person care, while others received telehealth. Results were analyzed using multiple regression. Results: Mean DUDIT-C scores improved with treatment in both cohorts. Changes on the DUDIT-C were related to initial scores. Treatment modality (telehealth vs in-person) had no distinguishable association with outcomes. Discussion and Conclusions: Results showed no discernible difference in outcomes between telehealth and in-person cohorts. Telehealth was as effective as in-person care in the treatment of substance use disorders, and appears to be equivalent to in-person care in rural outpatient settings.

Comparison of Telehealth and In-Person Behavioral Health Services and Payment in a Large Rural Multisite Usual Care Study.

Background: Telehealth and in-person behavioral health services have previously shown equal effectiveness, but cost studies have largely been limited to travel savings for telehealth cohorts. The purpose of this analysis was to compare telehealth and in-person cohorts, who received behavioral health services in a large multisite study of usual care treatment approaches to examine relative value units (RVUs) and payment. Methods: We used current procedural terminology codes for each encounter to identify RVUs and Medicare payment rates. Mixed linear regression models compared telehealth and in-person cohorts on RVUs, per-encounter payment rates, and total-episode payment rates. Results: We found the behavioral health services provided by telehealth to have modest, but statistically significantly lower RVUs (i.e., less provider work in time spent and case complexity), per-encounter payments, and total episode payments than the in-person cohort. Despite Medicare rates discounting payments for nonphysician providers and the in-person cohort using clinical social workers more frequently, the services provided by the telehealth cohort still had lower payments. Thus, the differences observed are due to the in-person cohort receiving higher payment RVU services than the telehealth cohort, which was more likely to receive briefer therapy sessions and other less expensive services. Conclusions: Behavioral health services provided by telehealth used services with lower RVUs than behavioral health services provided in-person, on average, even after adjusting for patient demographics and diagnosis. Observed differences in Medicare payments resulted from the provider type and services used by the two cohorts; thus, costs and insurance reimbursements may vary for others.

The impact of Medicare shared savings program participation on hospital financial performance: An event-study analysis.

OBJECTIVE: To evaluate the impact of hospitals' participation in the Medicare Shared Savings Program (MSSP) on their financial performance. DATA SOURCES: Centers for Medicare & Medicaid Services Hospital Cost Reports and MSSP Accountable Care Organizations (ACO) Provider-Level Research Identifiable File from 2011 to 2018. STUDY DESIGN: We used an event-study design to estimate the temporal effects of MSSP participation on hospital financial outcomes and compared within-hospital changes over time between MSSP and non-MSSP hospitals while controlling for hospital and year fixed effects and organizational and service-area characteristics. The following financial outcomes were evaluated: outpatient revenue, inpatient revenue, net patient revenue, Medicare revenue, operating margin, inpatient revenue share, Medicare revenue share, and allowance and discount rate. DATA COLLECTION/EXTRACTION METHODS: Secondary data linked at the hospital level. PRINCIPAL FINDINGS: Controlling for trends in non-MSSP hospitals, MSSP participation was associated with differential increases in net patient revenue by $3.28 million (p < 0.001), $3.20 million (p < 0.01), and $4.20 million (p < 0.01) in the second, third, and fourth year and beyond after joining MSSP, respectively. Medicare revenue differentially increased by $1.50 million (p < 0.05), $2.24 million (p < 0.05), and $4.47 million (p < 0.05) in the first, second, and fourth year and beyond. Inpatient revenue share differentially increased by 0.29% (p < 0.05) in the second year and 0.44% (p < 0.05) in the fourth year and beyond. Medicare revenue share differentially increased by 0.17% (p < 0.01), 0.25% (p < 0.01), 0.32% (p < 0.01), and 0.41% (p < 0.01) in consecutive years following MSSP participation. MSSP participation was associated with 0.33% (p < 0.05) and 0.39% (p < 0.05) differential reduction in allowance and discount rate in the second and third years. CONCLUSIONS: MSSP participation was associated with differential increases in net patient revenue, Medicare revenue, inpatient revenue share, and Medicare revenue share, and a differential reduction in allowance and discount rate.

Telehealth Services for Primary Care and Urgent Care to Support Rural Schools and Students.

Background: School-based health services, particularly those available to underserved and rural communities, remain in high demand. Advancements in telehealth services present clinical resources otherwise typically unavailable to students from rural communities. Methods: Data were collected during 4 semesters on all students receiving primary care or urgent care health services from 8 school-based telehealth programs delivering care to 40 schools across the United States. Results: Across the 4 semesters, 2,769 students received primary care telehealth and 2,238 students received urgent care telehealth. The primary care telehealth services were delivered by a primary care provider with a registered nurse also involved in half of the encounters. In contrast, the urgent care telehealth services were delivered almost exclusively by a registered nurse. Primary care telehealth delivered a variety of services including medication management, counseling, and sports physicals in addition to assessments and evaluations. Urgent care telehealth primarily involved an assessment. Both services returned most students to the classroom without the need for further follow-up, thus reducing or eliminating the need for seeking health care outside of the school setting. Notably, 67.7% of students seeking primary care telehealth services did not have a primary care provider outside of the school, clearly demonstrating the importance of these school-based services in increasing access to basic health care services for these students in rural and underserved communities. Conclusions: Telehealth provides a reliable solution and immediate access to care for students in need of health care, which, in turn, presents advantages to educators and parents.

Medicare accountable care organization characteristics associated with participation in 2-sided risk.

PURPOSE: To examine the associations of accountable care organization (ACO) characteristics with the likelihood of participation in 2-sided risk tracks in the Medicare Shared Savings Program (SSP). METHODS: CMS ACO Public Use Files and Provider-Level Research Identifiable Files were used to trace Medicare ACOs' participation in the SSP between 2012 and 2020 and measure ACO characteristics, including size, rurality of the service area, affiliation with supporting organizations, program experience, and performance. Logistic regression and survival analysis were used to test the associations between ACO characteristics and the probability of ACOs initially participating in or subsequently switching to 2-sided risk tracks. FINDINGS: Among the 624 Medicare SSP ACOs that started between 2012 and 2017, 26 participated in 2-sided risk tracks in their initial contracts and 95 switched to 2-sided risk tracks subsequently. ACO characteristics were not significantly associated with the probability of participating in 2-sided risk tracks in initial contracts. ACO size, affiliation with supporting organizations, and performance were positively associated with the likelihood of switching to 2-sided risk. Rural ACOs were less likely to switch to 2-sided risk than their urban counterparts. CONCLUSIONS: Small and rural ACOs are less prepared to transition into 2-sided risk swiftly.

Overview of School-Based Telehealth Network Grant Program Services Delivered to Students in Rural Schools.

Telehealth can expand and enhance access to school-based health care, but its use has been relatively limited. Recognizing that school-based health care is still not reaching many students, the Health Resources and Services Administration (HRSA) funded the School Based Telehealth Network Grant Program to expand telehealth in rural school-based settings to help to increase the availability and use of these services. The 19 grantees delivered telehealth to over 200 schools across 17 states, choosing which services they would deliver and how. Looking across the services, these fell into three categories - primary/urgent care, behavioral health, and other more specialized services. The majority of grantees offered multiple telehealth services with the combination of behavioral health and primary/urgent care the most common. The current study adds to the literature by elucidating that telehealth in schools can address multiple clinical conditions through separate services even though doing so involves using various combinations of clinicians providing different services.

Comparison of in-person vs. telebehavioral health outcomes from rural populations across America.

BACKGROUND: This study investigates outcomes from two federal grant programs: the Evidence-Based Tele-Behavioral Health Network Program (EB THNP) funded from September 2018 to August 2021 and the Substance Abuse Treatment Telehealth Network Grant Program (SAT TNGP) funded from September 2017 to August 2020. As part of the health services implementation program, the aims of this study were to evaluate outcomes in patient symptoms of depression and anxiety across the programs' 17 grantees and 95 associated sites, with each grantee having data from telehealth patients and from an in-person comparison group. METHODS: The research design is a prospective multi-site observational study. Each grantee provided data on a nonrandomized convenience sample of telehealth patients and an in-person comparison group from sites with similar rural characteristics and during the same time period. Patient characteristics were collected at treatment initiation, and clinical outcome measures were collected at baseline and monthly. The validated clinical outcome measure instruments included the Patient Health Questionnaire-9 (PHQ-9) for depression symptoms and the Generalized Anxiety Disorder-7 (GAD-7) scale for anxiety-related symptoms. Linear mixed models, with grantee as the random effect, were used to determine the association of behavioral health delivery (telehealth versus in-person) on the one-month change in PHQ-9 and GAD-7 while adjusting for covariates. RESULTS: Across a total of 1,514 patients, one-month change scores were improved indicating that PHQ-9 and GAD-7 scores decreased from baseline to the one-month follow-up at similar rates in both the in-person and telehealth groups. Reduction in scores averaged 2.8 for the telehealth treatment group and 2.9 for the in-person treatment group in the PHQ-9 subsample and 2.0 for the telehealth treatment group and 2.4 for the in-person treatment group in the GAD-7 subsample. There was no statistically significant association between the modality of care (telehealth treatment group versus in-person comparison group) and the one-month change scores for either PHQ-9 or GAD-7. Individuals with higher baseline scores demonstrated the greatest decrease in scores for both measures. Upon adjusting for baseline scores and grantee program, patient demographics were not found to be significantly associated with change in anxiety or depression symptoms. CONCLUSION: In our very large pragmatic study comparing behavioral health treatment delivered to a population of patients in rural, underserved communities, we found no clinical or statistical differences in improvements in depression or anxiety symptoms as measured by the PHQ-9 and GAD-7 between patients treated via telehealth or in-person.

Two Teledentistry Models for the Provision of Essential Oral Health Care Services in Rural School Settings.

Purpose: Access to adequate dental services is limited for children in rural communities in the United States.The purpose of this paper was to describe how two school-based teledentistry programs increased access to oral health services for children and adolescents living in rural areas.Methods: The School-Based Telehealth Network Grant Program (SB TNGP) was designed to expand access to, and improve the quality of health care services in schools through telehealth. Data were collected from July 1 to December 31, 2019 on 164 students at 7 preschool sites by Marshfield Clinic Health System (MCHS) and on 1,467 students at 57 school sites by Children's Dental Services (CDS).Results: Both MCHS and CDS reported that over 99 percent of encounters were successfully completed using telehealth technology. Both grantees reported that 99.4 percent of students received an oral health evaluation/screening, primarily through a dental hygienist traveling to the school site connected to a dentist or advanced dental therapist through telehealth. One half of the students had dental caries (50.6 % MCHS; 48.6% CDS). Both grantees referred all students with dental caries for oral health follow-up care.Conclusions: By utilizing dental hygienists traveling to school sites and connecting with centrally located dental professionals through telehealth, both grantees increased access to needed oral health care services for rural children. Oral health screening in school settings using dental hygienists with teledentistry can provide an efficient way to identify students at high risk for dental caries and offer a valuable strategy for oral disease prevention and control.

An economic and health outcome evaluation of telehealth in rural sepsis care: a comparative effectiveness study.

Aim: Sepsis is a top contributor to in-hospital mortality and, healthcare expenditures and telehealth have been shown to improve short-term sepsis care in rural hospitals. This study will evaluate the effect of provider-to-provider video telehealth in rural emergency departments (EDs) on healthcare costs and long-term outcomes for sepsis patients. Materials & methods: We will use Medicare administrative claims to compare total healthcare expenditures, mortality, length-of-stay, readmissions, and category-specific costs between telehealth-subscribing and control hospitals. Results: The results of this work will demonstrate the extent to which telehealth use is associated with total healthcare expenditures for sepsis care. Conclusion: These findings will be important to inform future policy initiatives to improve sepsis care in rural EDs. Clinical Trial Registration: NCT05072145 (ClinicalTrials.gov).

Sepsis is a severe condition that results from infection. In addition to costly care, sepsis is a leading cause of death and disability. When comparing outcomes, those treated for sepsis in lower volume emergency departments fare worse and rural emergency departments often have lower patient volumes. While telehealth has been shown to improve sepsis care, the effect of telehealth on costs and long-term outcomes for patients is unclear. This study will use Medicare claims data to compare outcomes for people with sepsis in rural emergency departments who had video telehealth used with those who did not have video telehealth used, with the goal of measuring how telehealth affects healthcare costs, hospital readmissions and deaths after hospital discharge.

Describing Changes in Telebehavioral Health Utilization and Services Delivery in Rural School Settings in Pre- and Early Stages of the COVID-19 Public Health Emergency.

BACKGROUND: Receiving treatment for behavioral health disorders remains problematic due to profound provider shortages. Telebehavioral health services are effective for providing quality care, but research literature on these services in schools is limited. METHODS: Data were collected during Fall 2019 and Spring 2020 semesters on all students receiving telebehavioral health services from 15 school-based telehealth programs across the U.S. RESULTS: From Fall 2019 to Spring 2020, 62 schools providing services during both periods increased the number of students served from 396 to 745, increased the average number of encounters per student from 2.4 to 4.1, increased the percentage of encounters delivered by clinical social workers, mental health counselors, and clinical psychologists (all p < .001), and increased the use of individual counseling, family counseling, and group counseling (all p < .001). Schools that initiated the service in Spring 2020 (n = 25) averaged 6.5 encounters for the 301 students receiving services, delivered mostly by clinical social workers or professional counselors, using individual counseling. CONCLUSION: Overall, data indicate programs significantly increased both behavioral services provided to their ongoing schools and increased the number of schools served. Undoubtedly telebehavioral health care delivery provided a swift and necessary response to the challenges posed by the growing pandemic threat.

Nonmetropolitan COVID-19 Incidence and Mortality Rates Surpassed Metropolitan Rates Within the First 24 Weeks of the Pandemic Declaration: United States, March 1-October 18, 2020.

PURPOSE: This report compares COVID-19 incidence and mortality rates in the nonmetropolitan areas of the United States with the metropolitan areas across three 11-week periods from March 1 to October 18, 2020. METHODS: County-level COVID-19 case, death, and population counts were downloaded from USAFacts.org. The 2013 NCHS Urban-Rural Classification Scheme was collapsed into two categories called metropolitan (large central, large fringe, medium, and small metropolitans) and nonmetropolitan (micropolitan/noncore). Daily COVID-19 incidence and mortality rates were computed to show temporal trends for each of these two categories. Maps showing the ratio of nonmetropolitan to metropolitan COVID-19 incidence and mortality rates by state identify states with higher rates in nonmetropolitan areas than in metropolitan areas in each of the three 11-week periods. FINDINGS: In the period between March 1 and October 18, 2020, 13.8% of the 8,085,214 confirmed COVID-19 cases and 10.7% of the 217,510 deaths occurred among people residing in nonmetropolitan counties. The nonmetropolitan incidence and mortality trends steadily increased and surpassed those in metropolitan areas, beginning in early August. CONCLUSIONS: Despite the relatively small size of the US population living in nonmetropolitan areas, these areas have an equal need for testing, health care personnel, and mitigation resources. Having state-specific rural data allow the development of prevention messages that are tailored to the sociocultural context of rural locations.

HRSA's evidence-based tele-emergency network grant program: Multi-site prospective cohort analysis across six rural emergency department telemedicine networks.

BACKGROUND: The Health Resources and Services Administration (HRSA), Federal Office of Rural Health Policy (FORHP) funded the Evidence-Based Tele-Emergency Network Grant Program (EB TNGP) to serve the dual purpose of providing telehealth services in rural emergency departments (teleED) and systematically collecting data to inform the telehealth evidence base. This provided a unique opportunity to examine trends across multiple teleED networks and examine heterogeneity in processes and outcomes. METHOD AND FINDINGS: Six health systems received funding from HRSA under the EB TNGP to implement teleED services and they did so to 65 hospitals (91% rural) in 11 states. Three of the grantees provided teleED services to a general patient population while the remaining three grantees provided teleED services to specialized patient populations (i.e., stroke, behavioral health, critically ill children). Over a 26-month period (November 1, 2015 -December 31, 2017), each grantee submitted patient-level data for all their teleED encounters on a uniform set of measures to the data coordinating center. The six grantees reported a total of 4,324 teleED visits and 99.86% were technically successful. The teleED patients were predominantly adult, White, not Latinx, and covered by Medicare or private insurance. Across grantees, 7% of teleED patients needed resuscitation services, 58% were rated as emergent, and 30% were rated as urgent. Across grantees, 44.2% of teleED patients were transferred to another inpatient facility, 26.0% had a routine discharge, and 24.5% were admitted to the local inpatient facility. For the three grantees who served a general patient population, the most frequent presenting complaints for which teleED was activated were chest pain (25.7%), injury or trauma (17.1%), stroke symptoms (9.9%), mental/behavioral health (9.8%), and cardiac arrest (9.5%). The teleED consultation began before the local clinician exam in 37.8% of patients for the grantees who served a general patient population, but in only 1.9% of patients for the grantees who provided specialized services. CONCLUSIONS: Grantees used teleED services for a representative rural population with urgent or emergent symptoms largely resulting in transfer to a distant hospital or inpatient admission locally. TeleED was often available as the first point of contact before a local provider examination. This finding points to the important role of teleED in improving access for rural ED patients.

Paediatric tele-emergency care: A study of two delivery models.

INTRODUCTION: Tele-emergency models have been utilized for decades, with growing evidence of their effectiveness. Due to the variety of tele-emergency department (tele-ED) models used in practice, however, it is challenging to build standardized metrics for ongoing evaluation. This study describes two tele-ED programs, one specialized and one general, that provide care to paediatric populations. Through an examination of model structures and patient populations, we gain insight into how evaluative measures should reflect tele-ED model design and purpose. METHODS: Qualitative descriptions of the two tele-ED models are presented. We show a retrospective cohort analysis describing paediatric patients' key characteristics, reasons for visit, and disposition status by case/control status. Case/control patient encounter data were collected October 2015 through December 2017, from 15 spoke hospitals within each tele-ED program. RESULTS: The two tele-ED models serve distinct paediatric populations, and measures of tele-ED utilization and disposition reflect those differences. In the specialized University of California (UC) Davis Health program, tele-ED was utilized in 36% of paediatric critical care encounters and 78% of those were transferred. In the Avera eCARE program, tele-ED was activated in 1.7% of paediatric encounters and 50.6% of those were transferred. When Avera eCARE paediatric encounters were stratified by severity, measures of tele-ED use and disposition status among high-severity encounters were more similar to UC Davis Health. DISCUSSION: This study describes how design choices of tele-ED models have implications for evaluative measures. Measures of tele-ED model success need to reflect model purpose, populations served, and for whom tele-ED service use is appropriate.

Emergency department telemedicine consults decrease time to interpret computed tomography of the head in a multi-network cohort.

INTRODUCTION: Telemedicine can improve access to emergency stroke care in rural areas, but the benefit of telemedicine across different types and models of telemedicine networks is unknown. The objectives of this study were to (a) identify the impact of telemedicine on emergency department (ED) stroke care, (b) identify if telemedicine impact varied by network and (c) describe the variation in process outcomes by telemedicine across EDs. METHODS: A prospective cohort study identified stroke patients in four telemedicine networks between November 2015 and December 2017. Primary exposure was telemedicine consultation during ED evaluation. Outcomes included: (a) interpretation of computed tomography (CT) of the head within 45 minutes and (b) time to administer tissue plasminogen activator (tPA). An interaction term tested for differences in telemedicine effect on stroke care by network and hospital. RESULTS: Of the 932 stroke subjects, 36% received telemedicine consults. For subjects with a last known well time within two hours of ED arrival (27.9%), recommended CT interpretation within 45 minutes was met for 66.8%. Telemedicine was associated with higher odds of timely head CT interpretation (adjusted odds ratio = 3.03; 95% confidence interval (CI) 1.69-5.46). The magnitude of the association between telemedicine and time to interpret a CT of the head differed between telemedicine networks (interaction term p = 0.033). Among eligible patients, telemedicine was associated with faster time to administer tPA (adjusted hazard ratio = 1.81; 95% CI 1.31-2.50). DISCUSSION: Telemedicine consultation during the ED encounter decreased the time to interpret at CT of the head among stroke patients, with differing magnitudes of benefit across telemedicine networks. The effect of heterogeneity of telestroke affects across different networks should be explored in future analyses.

Averted Transfers in Rural Emergency Departments Using Telemedicine: Rates and Costs Across Six Networks.

Objective: This analysis identified the rate of transfers and averted transfers and their associated costs across multiple emergency department telemedicine (teleED) networks. Methods: This study is a prospective cohort analysis in six teleED networks operating in 65 hospitals in 11 states across the United States. Each submitted uniform data on all teleED encounters for a 26-month period to a data co-ordinating center. Averted transfers were identified if an encounter met specific criteria. Cost savings from averted transfers were estimated from hospital-specific costs of transferred patients. Results: A total of 4,324 teleED encounters were reported. Excluding patients who died, 1,934 (46.2%) were transferred to another inpatient facility. Records of the remaining 2,248 teleED patients were examined and 882 (39.2% of nontransfers; 20.4% of all teleED cases) teleED patients met the criteria for an averted transfer. Of the averted transfer cases, 53.3% were admitted to the local inpatient facility, and 43.5% were discharged. Patients who averted transfer had lower levels of severity and less billed services than those who were transferred. Transport savings for averted transfers were estimated to total $1,074,663 annually across the six teleED networks. Average estimated transport savings were $2,673 for each averted transfer. Conclusions: In a large cohort of teleED cases, 39% of nontransfer cases were averted transfers (20% of all teleED cases). Importantly, 43% of these patients were routinely discharged rather than being transferred. Averted transfers saved on average $2,673 in avoidable transport costs per patient, with 63.6% of these cost savings accruing to public insurance.

Provider-to-provider telemedicine improves adherence to sepsis bundle care in community emergency departments.

INTRODUCTION: Sepsis is a life-threatening emergency. Together, early recognition and intervention decreases mortality. Protocol-based resuscitation in the emergency department (ED) has improved survival in sepsis patients, but guideline-adherent care is less common in low-volume EDs. This study examined the association between provider-to-provider telemedicine and adherence with sepsis bundle components in rural community hospitals. METHODS: This is a prospective cohort study of adults presenting with sepsis or septic shock in community EDs participating in rural telemedicine networks. The primary outcome was adherence to four sepsis bundle requirements: lactate measurement within 3 hours, blood culture before antibiotics, broad-spectrum antibiotics, and adequate fluid resuscitation. Multivariable generalized estimating equations estimated the association between telemedicine and adherence. RESULTS: In this cohort (n = 655), 5.6% of subjects received ED telemedicine consults. The telemedicine group was more likely to be male and have a higher severity of illness. After adjusting for severity and chief complaint, total sepsis bundle adherence was higher in the telemedicine group compared with the non-telemedicine group (aOR 17.27 [95%CI 6.64-44.90], p < 0.001). Telemedicine consultation was associated with higher adherence with three of the individual bundle components: lactate, antibiotics, and fluid resuscitation. DISCUSSION: Telemedicine patients were more likely to receive initial blood lactate measurement, timely broad-spectrum antibiotics, and adequate fluid resuscitation. In rural, community EDs, telemedicine may improve sepsis care and potentially reduce disparities in sepsis outcomes at low-volume facilities. Future work should identify specific components of telemedicine-augmented care that improve performance with sepsis quality indicators.