Long-term Telerehabilitation or Unsupervised Training at Home for Patients with Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial.

Rationale: Despite the benefits of pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD), many patients do not access or complete pulmonary rehabilitation, and long-term maintenance of exercise is difficult. Objectives: To compare long-term telerehabilitation or unsupervised treadmill training at home with standard care. Methods: In an international randomized controlled trial, patients with COPD were assigned to three groups (telerehabilitation, unsupervised training, or control) and followed up for 2 years. Telerehabilitation consisted of individualized treadmill training at home supervised by a physiotherapist and self-management. The unsupervised training group performed unsupervised treadmill exercise at home. The control group received standard care. The primary outcome was the combined number of hospitalizations and emergency department presentations. Secondary outcomes included time free from the first event; exercise capacity; dyspnea; health status; quality of life; anxiety; depression; self-efficacy; and subjective impression of change. Measurements and Main Results: A total of 120 participants were randomized. The incidence rate of hospitalizations and emergency department presentations was lower in telerehabilitation (1.18 events per person-year; 95% confidence interval [CI], 0.94-1.46) and unsupervised training group (1.14; 95% CI, 0.92-1.41) than in the control group (1.88; 95% CI, 1.58-2.21; P < 0.001 compared with intervention groups). Telerehabilitation and unsupervised training groups experienced better health status for 1 year. Intervention participants reached and maintained clinically significant improvements in exercise capacity. Conclusions: Long-term telerehabilitation and unsupervised training at home in COPD are both successful in reducing hospital readmissions and can broaden the availability of pulmonary rehabilitation and maintenance strategies.

Telerehabilitation for chronic respiratory disease: a randomised controlled equivalence trial.

RATIONALE: Pulmonary rehabilitation is an effective treatment for people with chronic respiratory disease but is delivered to <5% of eligible individuals. This study investigated whether home-based telerehabilitation was equivalent to centre-based pulmonary rehabilitation in people with chronic respiratory disease. METHODS: A multicentre randomised controlled trial with assessor blinding, powered for equivalence was undertaken. Individuals with a chronic respiratory disease referred to pulmonary rehabilitation at four participating sites (one rural) were eligible and randomised using concealed allocation to pulmonary rehabilitation or telerehabilitation. Both programmes were two times per week for 8 weeks. The primary outcome was change in Chronic Respiratory Disease Questionnaire Dyspnoea (CRQ-D) domain at end-rehabilitation, with a prespecified equivalence margin of 2.5 points. Follow-up was at 12 months. Secondary outcomes included exercise capacity, health-related quality of life, symptoms, self-efficacy and psychological well-being. RESULTS: 142 participants were randomised to pulmonary rehabilitation or telerehabilitation with 96% and 97% included in the intention-to-treat analysis, respectively. There were no significant differences between groups for any outcome at either time point. Both groups achieved meaningful improvement in dyspnoea and exercise capacity at end-rehabilitation. However, we were unable to confirm equivalence of telerehabilitation for the primary outcome ΔCRQ-D at end-rehabilitation (mean difference (MD) (95% CI) -1 point (-3 to 1)), and inferiority of telerehabilitation could not be excluded at either time point (12-month follow-up: MD -1 point (95% CI -4 to 1)). At end-rehabilitation, telerehabilitation demonstrated equivalence for 6-minute walk distance (MD -6 m, 95% CI -26 to 15) with possibly superiority of telerehabilitation at 12 months (MD 14 m, 95% CI -10 to 38). CONCLUSION: telerehabilitation may not be equivalent to centre-based pulmonary rehabilitation for all outcomes, but is safe and achieves clinically meaningful benefits. When centre-based pulmonary rehabilitation is not available, telerehabilitation may provide an alternative programme model. TRIAL REGISTRATION NUMBER: ACtelerehabilitationN12616000360415.

Telerehabilitation versus traditional centre-based pulmonary rehabilitation for people with chronic respiratory disease: protocol for a randomised controlled trial.

BACKGROUND: Pulmonary rehabilitation is an effective therapeutic intervention for people with chronic respiratory disease. However, fewer than 5% of eligible individuals receive pulmonary rehabilitation on an annual basis, largely due to limited availability of services and difficulties associated with travel and transport. The Rehabilitation Exercise At Home (REAcH) study is an assessor-blinded, multi-centre, randomised controlled equivalence trial designed to compare the efficacy of home-based telerehabilitation and traditional centre-based pulmonary rehabilitation in people with chronic respiratory disease. METHODS: Participants will undertake an 8-week group-based pulmonary rehabilitation program of twice-weekly supervised exercise training, either in-person at a centre-based pulmonary rehabilitation program or remotely from their home via the Internet. Supervised exercise training sessions will include 30 min of aerobic exercise (cycle and/or walking training). Individualised education and self-management training will be delivered. All participants will be prescribed a home exercise program of walking and strengthening activities. Outcomes will be assessed by a blinded assessor at baseline, after completion of the intervention, and 12-months post intervention. The primary outcome is change in dyspnea score as measured by the Chronic Respiratory Questionnaire - dyspnea domain (CRQ-D). Secondary outcomes will evaluate the efficacy of telerehabilitation on 6-min walk distance, endurance cycle time during a constant work rate test, physical activity and quality of life. Adherence to pulmonary rehabilitation between the two models will be compared. A full economic analysis from a societal perspective will be undertaken to determine the cost-effectiveness of telerehabilitation compared to centre-based pulmonary rehabilitation. DISCUSSION: Alternative models of pulmonary rehabilitation are required to improve both equity of access and patient-related outcomes. This trial will establish whether telerehabilitation can achieve equivalent improvement in outcomes compared to traditional centre-based pulmonary rehabilitation. If efficacious and cost-effective, the proposed telerehabilitation model is designed to be rapidly deployed into clinical practice. TRIAL REGISTRATION: Clinical trial registered with the Australian and New Zealand Clinical Trials Register at ( ACTRN12616000360415 ). Registered 21 March 2016.

Long-term integrated telerehabilitation of COPD Patients: a multicentre randomised controlled trial (iTrain).

BACKGROUND: Pulmonary rehabilitation (PR) is an effective intervention for the management of people with chronic obstructive pulmonary disease (COPD). However, available resources are often limited, and many patients bear with poor availability of programmes. Sustaining PR benefits and regular exercise over the long term is difficult without any exercise maintenance strategy. In contrast to traditional centre-based PR programmes, telerehabilitation may promote more effective integration of exercise routines into daily life over the longer term and broaden its applicability and availability. A few studies showed promising results for telerehabilitation, but mostly with short-term interventions. The aim of this study is to compare long-term telerehabilitation with unsupervised exercise training at home and with standard care. METHODS/DESIGN: An international multicentre randomised controlled trial conducted across sites in three countries will recruit 120 patients with COPD. Participants will be randomly assigned to telerehabilitation, treadmill and control, and followed up for 2 years. The telerehabilitation intervention consists of individualised exercise training at home on a treadmill, telemonitoring by a physiotherapist via videoconferencing using a tablet computer, and self-management via a customised website. Patients in the treadmill arm are provided with a treadmill only to perform unsupervised exercise training at home. Patients in the control arm are offered standard care. The primary outcome is the combined number of hospitalisations and emergency department presentations. Secondary outcomes include changes in health status, quality of life, anxiety and depression, self-efficacy, subjective impression of change, physical performance, level of physical activity, and personal experiences in telerehabilitation. DISCUSSION: This trial will provide evidence on whether long-term telerehabilitation represents a cost-effective strategy for the follow-up of patients with COPD. The delivery of telerehabilitation services will also broaden the availability of PR and maintenance strategies, especially to those living in remote areas and with no access to centre-based exercise programmes. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02258646 .

Adoption of routine telemedicine in Norwegian hospitals: progress over 5 years.

BACKGROUND: Although Norway is well known for its early use of telemedicine to provide services for people in rural and remote areas in the Arctic, little is known about the pace of telemedicine adoption in Norway. The aim of the present study was to explore the statewide implementation of telemedicine in Norwegian hospitals over time, and analyse its adoption and level of use. METHODS: Data on outpatient visits and telemedicine consultations delivered by Norwegian hospitals from 2009 to 2013 were collected from the national health registry. Data were stratified by health region, hospital, year, and clinical specialty. RESULTS: All four health regions used telemedicine, i.e. there was 100 % adoption at the regional level. The use of routine telemedicine differed between health regions, and telemedicine appeared to be used mostly in the regions of lower centrality and population density, such as Northern Norway. Only Central Norway seemed to be atypical. Twenty-one out of 28 hospitals reported using telemedicine, i.e. there was 75 % adoption at the hospital level. Neurosurgery and rehabilitation were the clinical specialties where telemedicine was used most frequently. Despite the growing trend and the high adoption, the relative use of telemedicine compared to that of outpatient visits was low. CONCLUSIONS: Adoption of telemedicine is Norway was high, with all the health regions and most of the hospitals reporting using telemedicine. The use of telemedicine appeared to increase over the 5-year study period. However, the proportion of telemedicine consultations relative to the number of outpatient visits was low. The use of telemedicine in Norway was low in comparison with that reported in large-scale telemedicine networks in other countries. To facilitate future comparisons, data on adoption and utilisation over time should be reported routinely by statewide or network-based telemedicine services.

Telerehabilitation Compared to Center-based Pulmonary Rehabilitation for People with Chronic Respiratory Disease: Economic Analysis of a Randomized, Controlled Clinical Trial.

RATIONALE: New pulmonary rehabilitation models can improve access to this effective but underutilised treatment for people with chronic respiratory disease, however cost effectiveness has not been determined. OBJECTIVE: To compare the cost effectiveness of telerehabilitation, including videoconferencing and synchronous supervision, to standard center-based pulmonary rehabilitation. METHODS: Prospective economic analyses were undertaken from a societal perspective alongside a randomised controlled equivalence trial in which adults with stable chronic respiratory disease undertook an 8-week outpatient center-based program or telerehabilitation. Clinical assessment for effectiveness (Chronic Respiratory Disease Questionnaire dyspnoea domain [CRQ-D] score) was undertaken at baseline, following pulmonary rehabilitation and 12-month follow-up. Individual-level administrative and self-report healthcare cost data were collected over 12 months following the program (Australian dollars, 2020) Results: There were no between-group differences for effectiveness (CRQ-D MD -0.2 [SE 1.0], p=0.61) or total costs ($565 [5452], p=0.92) over 12 months. On the cost effectiveness plane, 97.4% of estimates fell between the equivalence margins for effectiveness. Application of a range of values for cost margin demonstrated a 95% probability that telerehabilitation was equivalent to center-based pulmonary rehabilitation when the threshold was $11,000. Results were robust to approach, sensitivity and subgroup analyses. The internal rate of return was 134% over 5 years. Program completion (regardless of model) was associated with a significant reduction in total costs in the following 12 months (ß $-17,960, 95%CI -29,967 to -5952). Conclusions This study supports delivery of telerehabilitation as a cost-effective alternative model of pulmonary rehabilitation for people with chronic respiratory disease.

A simple, generalizable method for measuring individual research productivity and its use in the long-term analysis of departmental performance, including between-country comparisons.

BACKGROUND: A simple, generalizable method for measuring research output would be useful in attempts to build research capacity, and in other contexts. METHODS: A simple indicator of individual research output was developed, based on grant income, publications and numbers of PhD students supervised. The feasibility and utility of the indicator was examined by using it to calculate research output from two similarly-sized research groups in different countries. The same indicator can be used to assess the balance in the research "portfolio" of an individual researcher. RESULTS: Research output scores of 41 staff in Research Department A had a wide range, from zero to 8; the distribution of these scores was highly skewed. Only about 20% of the researchers had well-balanced research outputs, with approximately equal contributions from grants, papers and supervision. Over a five-year period, Department A's total research output rose, while the number of research staff decreased slightly, in other words research productivity (output per head) rose. Total research output from Research Department B, of approximately the same size as A, was similar, but slightly higher than Department A. CONCLUSIONS: The proposed indicator is feasible. The output score is dimensionless and can be used for comparisons within and between countries. Modeling can be used to explore the effect on research output of changing the size and composition of a research department. A sensitivity analysis shows that small increases in individual productivity result in relatively greater increases in overall departmental research output. The indicator appears to be potentially useful for capacity building, once the initial step of research priority setting has been completed.

Perceived Autonomy Support in Telerehabilitation by People With Chronic Respiratory Disease: A Mixed Methods Study.

BACKGROUND: Autonomy-supportive health environments can assist patients in achieving behavior change and can influence adherence positively. Telerehabilitation may increase access to rehabilitation services, but creating an autonomy-supportive environment may be challenging. RESEARCH QUESTION: To what degree does telerehabilitation provide an autonomy-supportive environment? What is the patient experience of an 8-week telerehabilitation program? STUDY DESIGN AND METHODS: Individuals undertaking telerehabilitation or center-based pulmonary rehabilitation within a larger randomized controlled equivalence trial completed the Health Care Climate Questionnaire (HCCQ; short form) to assess perceived autonomy support. Telerehabilitation participants were invited 1:1 to undertake semistructured interviews. Interviews were transcribed verbatim and coded thematically to identify major themes and subthemes. RESULTS: One hundred thirty-six participants (n = 69 telerehabilitation) completed the HCCQ and 30 telerehabilitation participants (42%) undertook interviews. HCCQ summary scores indicated that participants strongly agreed that the telerehabilitation environment was autonomy supportive, which was similar to center-based participants (HCCQ summary score, P = .6; individual HCCQ items, P ≥ .3). Telerehabilitation interview data supported quantitative findings identifying five major themes, with subthemes, as follows: (1) making it easier to participate in pulmonary rehabilitation, because telerehabilitation was convenient, saved time and money, and offered flexibility; (2) receiving support in a variety of ways, including opportunities for peer support and receiving an individualized program guided by expert staff; (3) internal and external motivation to exercise as a consequence of being in a supervised group, seeing results for effort, and being inspired by others; (4) achieving success through provision of equipment and processes to prepare and support operation of equipment and technology; and (5) after the rehabilitation program, continuing to exercise, but dealing with feelings of loss. INTERPRETATION: Telerehabilitation was perceived as an autonomy-supportive environment, in part by making it easier to undertake pulmonary rehabilitation. Support for behavior change, understanding, and motivation were derived from clinicians and patient-peers. The extent to which autonomy support translates into ongoing self-management and behavior change is not clear. TRIAL REGISTRY: Australian and New Zealand Clinical Trials Registry; No.: ACTRN12616000360415; URL: https://anzctr.org.au/.

Long-running telemedicine networks delivering humanitarian services: experience, performance and scientific output.

OBJECTIVE: To summarize the experience, performance and scientific output of long-running telemedicine networks delivering humanitarian services. METHODS: Nine long-running networks--those operating for five years or more--were identified and seven provided detailed information about their activities, including performance and scientific output. Information was extracted from peer-reviewed papers describing the networks' study design, effectiveness, quality, economics, provision of access to care and sustainability. The strength of the evidence was scored as none, poor, average or good. FINDINGS: The seven networks had been operating for a median of 11 years (range: 5-15). All networks provided clinical tele-consultations for humanitarian purposes using store-and-forward methods and five were also involved in some form of education. The smallest network had 15 experts and the largest had more than 500. The clinical caseload was 50 to 500 cases a year. A total of 59 papers had been published by the networks, and 44 were listed in Medline. Based on study design, the strength of the evidence was generally poor by conventional standards (e.g. 29 papers described non-controlled clinical series). Over half of the papers provided evidence of sustainability and improved access to care. Uncertain funding was a common risk factor. CONCLUSION: Improved collaboration between networks could help attenuate the lack of resources reported by some networks and improve sustainability. Although the evidence base is weak, the networks appear to offer sustainable and clinically useful services. These findings may interest decision-makers in developing countries considering starting, supporting or joining similar telemedicine networks.

'Online' geriatric assessment procedure for older adults referred for geriatric assessment during an acute care episode for consideration of reliability of triage decisions.

BACKGROUND: Comprehensive geriatric assessment has been shown to improve patient outcomes, but the geriatricians who deliver it are in short-supply. A web-based method of comprehensive geriatric assessment has been developed with the potential to improve access to specialist geriatric expertise. The current study aims to test the reliability and safety of comprehensive geriatric assessment performed "online" in making geriatric triage decisions. It will also explore the accuracy of the procedure in identifying common geriatric syndromes, and its cost relative to conventional "live" consultations. METHODS/DESIGN: The study population will consist of 270 acutely hospitalized patients referred for geriatric consultation at three sites. Paired assessments (live and online) will be conducted by independent, blinded geriatricians and the level of agreement examined. This will be compared with the level of agreement between two independent, blinded geriatricians each consulting with the patient in person (i.e. "live"). Agreement between the triage decision from live-live assessments and between the triage decision from live-online assessments will be calculated using kappa statistics. Agreement between the online and live detection of common geriatric syndromes will also be assessed using kappa statistics. Resource use data will be collected for online and live-live assessments to allow comparison between the two procedures. DISCUSSION: If the online approach is found to be less precise than live assessment, further analysis will seek to identify patient subgroups where disagreement is more likely. This may enable a protocol to be developed that avoids unsafe clinical decisions at a distance. TRIAL REGISTRATION NUMBER: ACTRN12611000936921.

Student perceptions of a hands-on practicum to supplement an online eHealth course.

BACKGROUND: Since 2000, the Centre for Online Health (COH) at The University of Queensland has offered a range of online eHealth courses at the undergraduate and postgraduate level. While online learning has a number of advantages, in some domains, it can present some challenges to the development of practical skills and experience. OBJECTIVE: To assess students' perceptions of the value of an eHealth practicum. METHODS: To supplement our online learning program, we introduced an eHealth practicum component that aimed to expose students to a range of clinically relevant learning experiences. Subsequently, by means of a questionnaire, student perceptions of the practicum were assessed. RESULTS: Over two semesters, a total of 66 students participated in the eHealth practicum, and questionnaire responses were very positive. The majority of students agreed that the practicum allowed them to gain necessary skills in eHealth applications (59%) and provided them with an opportunity to explore ways of using different eHealth tools for the delivery of health care at a distance (62%). CONCLUSIONS: The study shows that a practical component in eHealth teaching was well received by students. While online teaching is appropriate for providing knowledge, the opportunity to develop practical skills may encourage students to use eHealth techniques in their future practices.

Adoption of telemedicine: from pilot stage to routine delivery.

BACKGROUND: Today there is much debate about why telemedicine has stalled. Teleradiology is the only widespread telemedicine application. Other telemedicine applications appear to be promising candidates for widespread use, but they remain in the early adoption stage. The objective of this debate paper is to achieve a better understanding of the adoption of telemedicine, to assist those trying to move applications from pilot stage to routine delivery. DISCUSSION: We have investigated the reasons why telemedicine has stalled by focusing on two, high-level topics: 1) the process of adoption of telemedicine in comparison with other technologies; and 2) the factors involved in the widespread adoption of telemedicine. For each topic, we have formulated hypotheses. First, the advantages for users are the crucial determinant of the speed of adoption of technology in healthcare. Second, the adoption of telemedicine is similar to that of other health technologies and follows an S-shaped logistic growth curve. Third, evidence of cost-effectiveness is a necessary but not sufficient condition for the widespread adoption of telemedicine. Fourth, personal incentives for the health professionals involved in service provision are needed before the widespread adoption of telemedicine will occur. SUMMARY: The widespread adoption of telemedicine is a major -- and still underdeveloped -- challenge that needs to be strengthened through new research directions. We have formulated four hypotheses, which are all susceptible to experimental verification. In particular, we believe that data about the adoption of telemedicine should be collected from applications implemented on a large-scale, to test the assumption that the adoption of telemedicine follows an S-shaped growth curve. This will lead to a better understanding of the process, which will in turn accelerate the adoption of new telemedicine applications in future. Research is also required to identify suitable financial and professional incentives for potential telemedicine users and understand their importance for widespread adoption.

Use of provider-to-provider telemedicine in Kenya during the COVID-19 pandemic.

Introduction: According to the World Health Organization (WHO), about 90 percent of countries continue to report COVID-related disruptions to their health systems. The use of telemedicine has been especially common among high-income countries to safely deliver and access health services where enabling infrastructure like broadband connectivity is more widely available than low- and middle-income countries (LMICs). The Addis Clinic implements a provider-to-provider (P2P) asynchronous telemedicine model in Kenya. We sought to examine the use of the P2P telemedicine platform during the second year of COVID-19. Methods: To assess sustainability, we compared the data for two 12-month calendar periods (period A = year 2020, and period B = year 2021). To examine performance, we compared the data for two different 12-month periods (period C = pandemic period of February 2021 to January 2022, and period D = baseline period of February 2019 to January 2020). Results: Sustainability of the P2P telemedicine platform was maintained during the pandemic with increased activity levels from 2,604 cases in 2020 to 3,525 cases in 2021. There was an average of 82 specialists and 5.9 coordinators during 2020, and an average of 81 specialists and 6.0 coordinators during 2021. During 2020, there were 444 cases per coordinator, and 587 cases per coordinator in 2021(P = 0.078). During 2020, there were 32 cases per specialist, and 43 cases per specialist in 2021(P = 0.068). Performance decreased with 99 percent of cases flagged as "answered" during the baseline period (period D), and 75 percent of cases flagged as "answered" during the pandemic period (period C). Conclusion: Results suggest that despite a decline in certain sustainability and performance indicators, The Addis Clinic was able to sustain a very high level of activity during the second year of the pandemic, as shown by the continued use of the system. Furthermore, despite some of the infrastructure challenges present in LMICs, the P2P telemedicine platform was a viable option for receiving clinical recommendations from medical experts located remotely. As health systems in LMICs grapple with the effects of the pandemic, it is worthwhile to consider the use of telemedicine to deliver essential health services.

Estimating travel reduction associated with the use of telemedicine by patients and healthcare professionals: proposal for quantitative synthesis in a systematic review.

BACKGROUND: A major benefit offered by telemedicine is the avoidance of travel, by patients, their carers and health care professionals. Unfortunately, there is very little published information about the extent of avoided travel. We propose to undertake a systematic review of literature which reports credible data on the reductions in travel associated with the use of telemedicine. METHOD: The conventional approach to quantitative synthesis of the results from multiple studies is to conduct a meta analysis. However, too much heterogeneity exists between available studies to allow a meaningful meta analysis of the avoided travel when telemedicine is used across all possible settings. We propose instead to consider all credible evidence on avoided travel through telemedicine by fitting a linear model which takes into account the relevant factors in the circumstances of the studies performed. We propose the use of stepwise multiple regression to identify which factors are significant. DISCUSSION: Our proposed approach is illustrated by the example of teledermatology. In a preliminary review of the literature we found 20 studies in which the percentage of avoided travel through telemedicine could be inferred (a total of 5199 patients). The mean percentage avoided travel reported in the 12 store-and-forward studies was 43%. In the 7 real-time studies and in a single study with a hybrid technique, 70% of the patients avoided travel. A simplified model based on the modality of telemedicine employed (i.e. real-time or store and forward) explained 29% of the variance. The use of store and forward teledermatology alone was associated with 43% of avoided travel. The increase in the proportion of patients who avoided travel (25%) when real-time telemedicine was employed was significant (P = 0.014). Service planners can use this information to weigh up the costs and benefits of the two approaches.

Treating disordered speech and voice in Parkinson's disease online: a randomized controlled non-inferiority trial.

BACKGROUND: Telerehabilitation may be a feasible solution to the current problems faced by people with Parkinson's disease in accessing speech pathology services. AIM: To investigate the validity and reliability of online delivery of the Lee Silverman Voice Treatment (LSVT®) for the speech and voice disorder associated with Parkinson's disease. METHOD & PROCEDURES: Thirty-four participants with Parkinson's disease and mild-to-moderate hypokinetic dysarthria took part in the randomized controlled non-inferiority laboratory trial and received the LSVT® in either the online or the face-to-face environment. Online sessions were conducted via two personal computer-based videoconferencing systems with real-time and store-and-forward capabilities operating on a 128 kbit/s Internet connection. Participants were assessed pre- and post-treatment on acoustic measures of mean vocal sound pressure level, phonation time, maximum fundamental frequency range, and perceptual measures of voice, articulatory precision and speech intelligibility. OUTCOMES & RESULTS: Non-inferiority of the online LSVT® modality was confirmed for the primary outcome measure of mean change in sound pressure level on a monologue task. Additionally, non-significant main effects for the LSVT® environment, dysarthria severity, and interaction effects were obtained for all outcomes measures. Significant improvements following the LSVT® were also noted on the majority of measures. The LSVT® was successfully delivered online, although some networking difficulties were encountered on a few occasions. High participant satisfaction was reported overall. CONCLUSIONS & IMPLICATIONS: Online treatment for hypokinetic dysarthria associated with Parkinson's disease appears to be clinically valid and reliable. Suggestions for future research are outlined.

Referral Activity in Three Store-and-Forward Networks during the COVID-19 Coronavirus Pandemic.

We surveyed three well-established store-and-forward telemedicine networks to identify any changes during the first half of 2020, which might have been due to the effect of the COVID-19 coronavirus pandemic on their telemedicine operations. The three networks all used the Collegium Telemedicus system. Various quantitative performance indicators, which included the numbers of referrals and the case-mix, were compared with their values in previous years. Two of the three networks surveyed (A and B) provided telemedicine services for any type of medical or surgical case, while the third (network C) handled only pediatric radiology cases. All networks operated in Africa, but networks A and C also provided services in other resource-constrained regions. Two of the networks (networks B and C) used local staff to submit referrals, while network A relied mainly on its expatriate staff. During the first half of 2020, the numbers of referrals received on network B increased substantially, while in contrast, the numbers of referrals on network A declined. All three networks had relatively stable referral rates during 2018 and 2019. All three networks delivered a service that was rated highly by the referrers. One network operated at relatively high efficiency compared to the other two, although it is not known if this is sustainable. The networks which were more reliant on local referrers saw little reduction-or even an increase-in submitted cases, while the network that had the most dependence on international staff saw a big fall in submitted cases. This was probably due to the effect of international travel restrictions on the deployment of its staff. We conclude that organizations wanting to build or expand their telemedicine services should consider deliberately empowering local providers as their referrers.

Increases in exposure calls related to selected cleaners and disinfectants at the onset of the COVID-19 pandemic: data from Canadian poison centres. / Augmentation du nombre d'appels relatifs à une exposition à certains nettoyants et désinfectants au début de la pandémie de COVID-19 : données des centres antipoison canadiens.

Little is known about the use or misuse of cleaning products during the COVID-19 pandemic. We compiled data from January to June in 2019 and 2020 from Canadian poison centres, and report on calls regarding selected cleaning products and present year-overyear percentage change. There were 3408 (42%) calls related to bleaches; 2015 (25%) to hand sanitizers; 1667 (21%) to disinfectants; 949 (12%) to chlorine gas; and 148 (2%) to chloramine gas. An increase in calls occurred in conjunction with the onset of COVID-19, with the largest increase occurring in March. Timely access to Canadian poison centre data facilitated early communication of safety messaging for dissemination to the public.

The Canadian Surveillance System for Poison Information (CSSPI) led by Health Canada is a developing network of poison centres, health authorities and regulatory agencies that facilitates early detection of poisoning incidents and alerting at the national level to inform harm reduction interventions. In response to the COVID-19 pandemic, concerns were raised over the potential for misuse of cleaning products and disinfectants; the CSSPI network monitored and assessed these concerns. An overall increase in calls about select cleaning products and disinfectants occurred concurrently with the pandemic, with percentage increases for selected products as high as 400% compared to the same period in the previous year.

Le Système canadien de surveillance des données sur les intoxications (SCSDI), dirigé par Santé Canada, est un réseau en développement composé de centres antipoison, d'autorités sanitaires et d'organismes de réglementation, qui facilite la détection précoce des incidents d'empoisonnement et une alerte rapide au niveau national afin d'éclairer les interventions en matière de réduction des risques. En réponse à la pandémie de COVID-19, des préoccupations ayant émergé quant au risque de mauvaise utilisation de produits de nettoyage et de désinfectants, le SCSDI a surveillé et évalué ces préoccupations. Une augmentation globale du nombre d'appels concernant plusieurs produits de nettoyage et désinfectants a eu lieu en concomitance avec la pandémie, certaines augmentations pouvant atteindre jusqu'à 400 % pour certains produits par rapport à la même période de l'année précédente.

A randomized controlled trial of an interactive voice response telephone system and specialist nurse support for childhood asthma management.

OBJECTIVES: To evaluate the effects of an automated interactive voice response system (IVR) and Specialist Nurse Support to reduce health care utilization and improve health-related quality of life in children with asthma. STUDY DESIGN: A randomized controlled trial in 121 children with doctor-diagnosed asthma and an acute presentation with asthma in the previous 12 months aged between 3 and 16 years. Children were randomized to one of three groups for a 6-month intervention receiving asthma education and management support from a Specialist Nurse by telephone or e-mail (N = 41), from IVR (N = 39), or receiving usual care (control group; N = 41). Outcomes included health care utilization and use of oral steroid rescue. Health-related quality of life (HRQOL) data using the Pediatric Asthma Quality of Life Questionnaire and Pediatric Quality of Life Inventory were collected at baseline and at the end of the study. RESULTS: There was no statistically significant benefit identified for either the IVR or the Nurse Support interventions for health care utilization, use of oral steroid rescue, or HRQOL compared with controls. Relative to controls, the incremental costs were -A$225.73 (95% confidence interval [CI]: -A$840, A$391) per child for the Nurse Support intervention and -A$451.45 (-A$1075, A$173) per child for IVR. The results were most sensitive to the frequency of admissions to hospital. CONCLUSION: This study suggested that both IVR and Nurse Support interventions may be cost-saving from a health system perspective, with IVR providing the greatest benefit and this pilot study provides a strong basis for developing larger trials with longer follow-up.

Randomised controlled trial of an automated, interactive telephone intervention to improve type 2 diabetes self-management (Telephone-Linked Care Diabetes Project): study protocol.

BACKGROUND: An estimated 285 million people worldwide have diabetes and its prevalence is predicted to increase to 439 million by 2030. For the year 2010, it is estimated that 3.96 million excess deaths in the age group 20-79 years are attributable to diabetes around the world. Self-management is recognised as an integral part of diabetes care. This paper describes the protocol of a randomised controlled trial of an automated interactive telephone system aiming to improve the uptake and maintenance of essential diabetes self-management behaviours. METHODS/DESIGN: A total of 340 individuals with type 2 diabetes will be randomised, either to the routine care arm, or to the intervention arm in which participants receive the Telephone-Linked Care (TLC) Diabetes program in addition to their routine care. The intervention requires the participants to telephone the TLC Diabetes phone system weekly for 6 months. They receive the study handbook and a glucose meter linked to a data uploading device. The TLC system consists of a computer with software designed to provide monitoring, tailored feedback and education on key aspects of diabetes self-management, based on answers voiced or entered during the current or previous conversations. Data collection is conducted at baseline (Time 1), 6-month follow-up (Time 2), and 12-month follow-up (Time 3). The primary outcomes are glycaemic control (HbA1c) and quality of life (Short Form-36 Health Survey version 2). Secondary outcomes include anthropometric measures, blood pressure, blood lipid profile, psychosocial measures as well as measures of diet, physical activity, blood glucose monitoring, foot care and medication taking. Information on utilisation of healthcare services including hospital admissions, medication use and costs is collected. An economic evaluation is also planned. DISCUSSION: Outcomes will provide evidence concerning the efficacy of a telephone-linked care intervention for self-management of diabetes. Furthermore, the study will provide insight into the potential for more widespread uptake of automated telehealth interventions, globally. TRIAL REGISTRATION NUMBER: ACTRN12607000594426.

Assessing disordered speech and voice in Parkinson's disease: a telerehabilitation application.

BACKGROUND: Patients with Parkinson's disease face numerous access barriers to speech pathology services for appropriate assessment and treatment. Telerehabilitation is a possible solution to this problem, whereby rehabilitation services may be delivered to the patient at a distance, via telecommunication and information technologies. A number of studies have demonstrated the capacity of telerehabilitation to provide reliable and valid assessments of speech, voice and language. However, no studies have specifically focused on assessing patients with Parkinson's disease. AIMS: To investigate the validity and reliability of a telerehabilitation application for assessing the speech and voice disorder associated with Parkinson's disease. METHODS & PROCEDURES: Sixty-one participants with Parkinson's disease and hypokinetic dysarthria were simultaneously assessed in an online and face-to-face environment by two speech-language pathologists. The assessment protocol included perceptual measures of voice and oromotor function, articulatory precision, speech intelligibility, and acoustic measures of vocal sound pressure level, phonation time and pitch range. Online assessments were conducted via a personal computer-based videoconferencing system with store-and-forward capabilities, operating on a 128 kbit/s Internet connection. The level of agreement between the online and face-to-face ratings was determined using several different analyses, depending on the parameter. These included per cent close agreement, quadratic weighted Kappa, and the Bland and Altman limits of agreement. OUTCOMES & RESULTS: Per cent close agreement between the two environments was within a predetermined clinical criterion of 80% agreement for all voice and oromotor parameters, articulatory precision and speech intelligibility in conversation. Levels of agreement between the environments, based on quadratic weighted Kappa, ranged from poor to good for vocal parameters and from fair to very good for oromotor parameters. Bland and Altman limits of agreement analyses revealed comparability between online and face-to-face environments for vocal sound pressure level, phonation time, pitch range, sentence intelligibility and communication efficiency in reading. Intra- and inter-rater reliability scores for all tasks were comparable between the online and face-to-face environments. CONCLUSIONS & IMPLICATIONS: For the majority of parameters, comparable levels of agreement were achieved between the two environments. Online assessment of disordered speech and voice in Parkinson's disease appears to be valid and reliable. The telerehabilitation application described in this study provides evidence for the delivery of online assessment for the dysarthric speech disorder associated with Parkinson's disease.