Adherence to Emergency Department Referral Criteria in a Direct-to-Consumer Telemedicine Center.

Background: The safety of direct-to-consumer telemedicine (TM) is closely related to red flag detection and correct referrals. The adherence to referral criteria from current guidelines is not well quantified. Objective: To analyze the emergency department (ED) referral rate and adherence to referral guidelines in TM encounters of acutely ill patients calling a center that adopts stewardship protocols. Methods: This is a retrospective observational unicentric study, between March 2020 and March 2022, with patients who spontaneously sought direct-to-consumer urgent virtual medical assistance. A video-based teleconsultation was provided immediately after connection. Physicians managed situations according to their clinical judgment. Current guidelines, containing specific guidance for referral if red flags were identified, were available for consultation. Physicians' semiannual performance feedback was carried out. We analyzed the patterns for referral to immediate face-to-face medical evaluation and the agreement degree with the institutional guidelines. Results: A total of 232,197 patients were available, and 14,051 (6.05%) patients were referred to ED. A total of 8,829 (68.4%) referrals were based in specific guidelines according to the International Classification of Diseases hypothesis, and 8,708 (98.6%) were justified according to guidelines. Diarrhea had the highest guidelines' adherence to referral (97.6%), followed by COVID-19 (90%), headache (84.2%), and conjunctivitis (78.8%). Policies did not support 5,222 (31.6%) referrals, though 5,100 (97.6%) of these were justified according to the doctor's clinical judgment. Conclusion: TM doctors' assessment of acutely ill patients has high rates of adherence to guidelines regarding referral. Stewardship protocol adoption provides high rates of red flag description, even in the referral of nonpolicy diseases.

The Impact of International Classification of Disease-Triggered Prescription Support on Telemedicine: Observational Analysis of Efficiency and Guideline Adherence.

BACKGROUND: Integrating decision support systems into telemedicine may optimize consultation efficiency and adherence to clinical guidelines; however, the extent of such effects remains underexplored. OBJECTIVE: This study aims to evaluate the use of ICD (International Classification of Disease)-coded prescription decision support systems (PDSSs) and the effects of these systems on consultation duration and guideline adherence during telemedicine encounters. METHODS: In this retrospective, single-center, observational study conducted from October 2021 to March 2022, adult patients who sought urgent digital care via direct-to-consumer video consultations were included. Physicians had access to current guidelines and could use an ICD-triggered PDSS (which was introduced in January 2022 after a preliminary test in the preceding month) for 26 guideline-based conditions. This study analyzed the impact of implementing automated prescription systems and compared these systems to manual prescription processes in terms of consultation duration and guideline adherence. RESULTS: This study included 10,485 telemedicine encounters involving 9644 patients, with 12,346 prescriptions issued by 290 physicians. Automated prescriptions were used in 5022 (40.67%) of the consultations following system integration. Before introducing decision support, 4497 (36.42%) prescriptions were issued, which increased to 7849 (63.57%) postimplementation. The physician's average consultation time decreased significantly to 9.5 (SD 5.5) minutes from 11.2 (SD 5.9) minutes after PDSS implementation (P<.001). Of the 12,346 prescriptions, 8683 (70.34%) were aligned with disease-specific international guidelines tailored for telemedicine encounters. Primary medication adherence in accordance with existing guidelines was significantly greater in the decision support group than in the manual group (n=4697, 93.53% vs n=1389, 49.14%; P<.001). CONCLUSIONS: Most of the physicians adopted the PDSS, and the results demonstrated the use of the ICD-code system in reducing consultation times and increasing guideline adherence. These systems appear to be valuable for enhancing the efficiency and quality of telemedicine consultations by supporting evidence-based clinical decision-making.

Extending the paleontology-biogeography reciprocity with SDMs: Exploring models and data in reducing fossil taxonomic uncertainty.

Historically, studies aimed at prospecting and analyzing paleontological and neontological data to investigate species distribution have developed separately. Research at the interface between paleontology and biogeography has shown a unidirectional bias, mostly focusing on how paleontological information can aid biogeography to understand species distribution through time. However, the modern suit of techniques of ecological biogeography, particularly species distribution models (SDM), can be instrumental for paleontologists as well, improving the biogeography-paleontology interchange. In this study, we explore how to use paleoclimatic data and SDMs to support paleontological investigation regarding reduction of taxonomic uncertainty. Employing current data from two neotropical species (Lagostomus maximus and Myocastor coipus), we implemented SDMs and performed model validation comparing hindcasts with dated fossil occurrences (~14k and ~20k years back present, respectively). Finally, we employed the hindcasting process for two South American fossil records of a misidentified species of caiman (Caiman sp.) to show that C. latirostris is the most likely species identity of these fossils (among four candidate species: C. latirostris, C. yacare, C. crocodilus, and Melanosuchus niger). Possible limitations of the approach are discussed. With this strategy, we have shown that current developments in biogeography research can favour paleontology, extending the (biased) current interchange between these two scientific disciplines.