Specification of the health production function and its behavioral implications.

The health production function of the canonical health-capital model is generalized to allow the state of health to affect the total and marginal products of health investment. If the total and marginal products of health investment are nonincreasing functions of the state of health, then the solution of the generalized model is locally qualitatively identical to that of the canonical model. Moreover, and in contrast to the canonical model, the generalized model is able to rationalize the cycling of the state of health and health investment observed in some individuals. The necessary conditions on the health production function for cyclical behavior are identified as well.

Primary extranodal B-cell non-Hodgkin lymphoma mimicking an endodontic lesion: report of 2 cases.

Intrabony oral non-Hodgkin lymphoma (NHL) is rare. We report 2 cases of NHL of the maxilla that initially presented as apical abscesses in endodontically treated teeth. Radiographic findings were nondescript, but tissue biopsy revealed diffuse large B-cell NHL in both instances. No other sites of disease were found. Both patients were treated by chemotherapy and radiation with good results. As primary NHL of the maxilla can mimic a dental inflammatory lesion, tissue biopsy is mandatory in cases where symptoms do not resolve after specific treatment.

Telemedicine to a moving ambulance improves outcome after trauma in simulated patients.

BACKGROUND: Rural trauma victims often require prolonged transport by s with limited scopes of practice. We evaluated the impact of telemedicine (TM) to a moving ambulance on outcomes in simulated trauma patients. METHODS: This is an institutional review board approved, prospective double-blind study. Three trauma scenarios (blunt torso trauma, epigastric stab wound, and closed head injury) were created for a human patient simulator. Intermediate emergency medical technicians (EMTs; n = 20) managed the human patient simulator, in a moving ambulance. In the TM group, physicians (n = 12) provided consultation. In the non-TM group, EMTs communicated with medical control by radio, as necessary. We tabulated the fraction of 13 key signs, 5 pathologic processes, and 12 key interventions that were performed. Vital signs and Sao2 (%) were recorded. Data were compared using the Wilcoxon rank-sum test. RESULTS: Lowest Sao2 (84 ± 0.7 vs. 78 ± 0), lowest systolic blood pressure (70 ± 1 vs. 53 ± 1), and highest heart rate (144 ± 0.9 vs. 159 ± 0.5) were significantly improved in the TM group (p < 0.001). Recognition rates for key signs (0.96 ± 0.01 vs. 0.79 ± 0.05), processes (0.98 ± 0.02 vs. 0.75 ± 0.05), and critical interventions (0.92 ± 0.02 vs. 0.49 ± 0.03) were higher in the TM group (p < 0.003). EMTs were successfully guided through needle decompression procedures in 22 of 24 cases (zero in the non-TM group). CONCLUSION: TM to a moving ambulance improved the care of simulated trauma patients. Furthermore, procedurally naïve EMTs were able to perform needle thoracostomy and pericardiocentesis with TM guidance.

Non-life-threatening ailments and rational patience when expected treatment outcomes are continuously improving.

The time at which a rational patient chooses to undergo an elective medical procedure for a non-life-threatening ailment is contemplated. The resulting model is purposely uncomplicated but general, and accounts for several basic factors that might affect such a decision. One such factor is that a patient cannot know with certainty the degree to which the medical procedure will be successful. Even so, patients have information about the expected outcome of the procedure and its risk, and about how the expected outcome and risk are affected by medical technological progress and surgeon experience. The effect of changes in exogenous variables on the timing of the medical procedure and on patient expected lifetime utility are investigated. It is shown that risk averse and prudent patients behave in an unambiguous manner in response to changes in all of the exogenous variables.

Benefits of a telepsychiatry consultation service for rural nursing home residents.

Psychiatric care for nursing home residents is difficult to obtain, especially in rural areas, and this deficiency may lead to significant morbidity or death. Providing this service by videoconference may be a helpful, cost-effective, and acceptable alternative to face-to-face treatment. We analyzed data for 278 telepsychiatry encounters for 106 nursing home residents to estimate potential cost and time savings associated with this modality compared to in-person care. A total of 843.5 hours (105.4 8-hour work days) of travel time was saved compared to in-person consultation for each of the 278 encounters if they had occurred separately. If four resident visits were possible for each trip, the time saved would decrease to 26.4 workdays. Travel distance saved was 43,000 miles; 10,750 miles if four visits per trip occurred. More than $3,700 would be spent on gasoline for 278 separate encounters; decreased to $925 for four visits per roundtrip. Personnel cost savings estimates ranged from $33,739 to $67,477. Physician costs associated with additional travel time ranged from $84,347 to $253,040 for 278 encounters, or from $21,087 to $63,260 for four encounters per visit. The telepsychiatry approach was enthusiastically accepted by virtually all residents, family members, and nursing home personnel, and led to successful patient management. Providing psychiatric care to rural nursing home residents by videoconference is cost effective and appears to be a medically acceptable alternative to face-to-face care. In addition, this approach will allow many nursing homes to provide essential care that would not otherwise be available.

Pediatric critical care telemedicine in rural underserved emergency departments.

OBJECTIVE: A disparity in access to health care exists between rural and urban areas. Although 21% of children in the United States live in rural areas, only 3% of pediatric intensivists practice in rural areas. In an attempt to address this issue, we implemented a program of pediatric critical care telemedicine consultations in rural emergency departments (EDs) and report our results. PATIENTS AND METHODS: A prospective evaluation of pediatric critical care consultations in rural EDs was undertaken March 2006 through March 2008. A referral area with a population of 1,000,000 in 19 rural counties in Vermont and upstate New York comprised the study area. MEASUREMENTS AND MAIN RESULTS: Sixty-three telemedicine consultations were performed in 10 rural EDs. The average number of consultations was 6.3 per site (range 2-17). Minor technical issues were identified in 18 consultations (29%). There were 12 primary diagnoses. Telemedicine was used to supervise the critical care transport team on 25 occasions (40%). Consulting intensivists made 236 specific recommendations. Consulting intensivists thought that telemedicine consultations improved patient care 89% of the time, were superior to telephone consultations 91% of the time, and provided good to very good provider-to-provider communications 98% of the time. Referring providers reported that telemedicine consultations improved patient care 88% of the time, were superior to telephone consultations 55% of the time, and provided good to very good communications 94% of the time. CONCLUSIONS: With telemedicine, it is feasible to provide urgent subspecialty critical care for children in underserved rural EDs, improve patient care, and provide a high degree of provider satisfaction. Pediatric critical care telemedicine may help to address the disparities in the access to and the outcome of medical care between rural and urban areas.

The feasibility of using ultrasound and video laryngoscopy in a mobile telemedicine consult.

Emergency healthcare systems in rural communities often have limited access to experienced trauma and emergency physicians. Advanced telecommunication technologies may offer an opportunity to help meet this need. We evaluated healthcare providers' satisfaction with the audio and visual components of an existing telemedicine system, and asked them whether emergency medical services (EMS) personnel could be supported via telemedicine guidance, using video laryngoscopy and ultrasonography, during vulnerable transport periods. Physicians and technologists at a central workstation were linked to a telemedicine-equipped ambulance providing real-time audio and visual communications during patient transport. A scoring system was created for system evaluation using a scale of 1-9. Seven evaluators observed ultrasonography of the carotid vessels and abdominal aorta. Nine evaluators observed an intubation with video laryngoscopy. These observers rated the quality of the images transmitted from the ambulance. Evaluators were asked if this telemedicine system would be suitable for telementoring advanced technical procedures. Mean rating for technical satisfaction with ultrasound was 5.1, the majority of evaluators estimated that they could telementor an abdominal ultrasound examination. The mean rating for technical satisfaction with laryngoscopy was 7.2 with 100% of evaluators estimating they could use the system to telementor intubation. The rating for laryngoscopy was significantly higher than for ultrasound (p = 0.01). Results of this study suggest that telemedicine may provide an advanced support mechanism for rural EMS personnel and patients. Procedures for advanced airway management and ultrasound diagnosis may someday be managed using a remote telepresence.

Effectiveness of lectures attended via interactive video conferencing versus in-person in preparing third-year internal medicine clerkship students for Clinical Practice Examinations (CPX).

BACKGROUND: The current practice in medical education is to place students at off-site locations. The effectiveness of these students attending remote lectures using interactive videoconferencing needs to be evaluated. PURPOSE: To determine whether lecture content covering clinical objectives is learned by medical students located at remote sites. METHODS: During the University of Vermont medicine clerkship, 52 medical students attended lectures both in person and via 2-way videoconferencing over a telemedicine network. The study used a crossover design, such that all students attended half of the lectures in person and half using videoconferencing. At the end of the clerkship, students were assessed via a Clinical Practice Examination (CPX), with each student completing 1 exam for material learned in person and 1 for material learned over telemedicine. RESULTS: Exam scores did not differ for the 2 lecture modes, with a mean score of 76% for lectures attended in person and a mean score of 78% for lectures attended via telemedicine (p = 0.66). CONCLUSIONS: Students learn content focused on clinical learning objectives as well using videoconferencing as they do in the traditional classroom setting.

The use of telemedicine for delivering continuing medical education in rural communities.

Physicians in rural communities have limited access to continuing medical education (CME) opportunities. We hypothesized that CME could be delivered via a telemedicine network as effectively as in-person. Our institution delivers CME lectures and grand rounds in Burlington, Vermont, for in-person attendees, and also via a telemedicine network that links 14 hospitals in Vermont and rural northeastern New York. All participants complete an evaluation questionnaire to receive CME credit. We compared the questionnaire responses of those attending in person with those attending via the telemedicine network. From October 1, 2000 to June 30, 2003, there were 4733 CME sessions, 650 of which had both in-person and telemedicine attendees. Responses from these 650 sessions were compared. Most questions relating to lecture quality scored higher for in-person attendees. Compared to having the presenter in the room, telemedicine attendance was judged to be "more effective" in 19% (n = 334), "as effective" in 60%, (n = 1074), and "less effective" in 21% (n = 367). Eighteen percent of telemedicine attendees said they would have traveled to attend the session. Telemedicine-delivered CME was considered at least as effective as in-person CME 79% of the time. Travel was avoided for 18% of the remote attendees. CME was delivered where it would not have been obtained for 82% of the remote attendees. Telemedicine systems can be used to deliver CME, in spite of lower overall ratings compared to in-person attendance.

Telemedicine reduces discrepancies in rural trauma care.

Patients injured in rural areas die at roughly twice the rate of those patients with similar injuries in urban areas. A multitude of explanations have been suggested for higher mortality rates from trauma in the rural areas of the United States. Since rural emergency room (ER) staff see far fewer traumas than ER staff at large metropolitan trauma centers, their lack of exposure to this low-volume problem certainly contributes to the problem. To address discrepancies in trauma education and the delivery of care in our rural region, a telemedicine system was utilized to provide rapid consultation from surgeons at the level 1 trauma center and to provide enhanced educational opportunities for rural ambulance emergency first responders. Clinical outcome measures and evaluation questionnaires were designed in advance of implementation. Forty-one "tele-trauma consults" were performed over the first 30 months of the project, all for major, multi-system trauma. Though many clinical recommendations were made, the system was judged to be life saving in three instances, and both rural and trauma center providers felt the system enhanced clinical care. In addition, educational sessions for rural first responders were well attended and favorably reviewed. Early results of a telemedicine system provide encouragement as a means to address discrepancies in the outcomes after major trauma in rural areas, although more work needs to be completed and evaluated.

Medical student evaluations of lectures attended in person or from rural sites via interactive videoconferencing.

BACKGROUND: Interactive videoconferencing may be an effective way for medical students on remote rotations to attend teaching sessions at the main campus. PURPOSE: To compare medical student evaluations of lectures for those attending in person and those attending through interactive videoconferencing. METHODS: Lecture evaluations were completed by medical students on University of Vermont College of Medicine clinical clerkship rotations. Students on clerkships at rural sites attended lectures using our telemedicine network. Responses from in-person and remote attendees were compared. RESULTS: Evaluation forms for 110 lectures were received from 648 in-person and 255 remote attendees. All evaluation items were rated "good" or "excellent" by at least 95% of in-person attendees. Over 90% of remote attendees rated nontelemedicine evaluation items, such as appropriateness of lecture topic for students, as good or excellent. Ratings of telemedicine-specific questions, such as ability to hear the lecturer, were lower. CONCLUSIONS: Level of satisfaction was high for most aspects of remote lecture attendance, although not quite as high as for in-person attendance. Improved technical reliability would likely increase remote attendee satisfaction. Overall, lecture attendance using videoconferencing was found to be an acceptable alternative to travel for medical students in rural clerkships.