Telestroke Infrastructure, Processes, and Support Needs: A Survey of Hospitals in Five States.

Introduction: Telestroke has been shown to be a cost-effective approach to promoting use and timeliness of evidence-based treatment. However, adoption of telestroke has been relatively low. Several barriers to telestroke implementation have been previously identified in the literature. These barriers, and the strategies needed to overcome them, may vary across hospitals. Our study aimed to examine telestroke programs to identify opportunities for future research and efforts to promote effective implementation and sustainment of telestroke services. Methods: We surveyed hospitals in five states to capture information about the current status of the hospital's telestroke program; the model(s) of delivery being used (e.g., hub-and-spoke and third-party vendor); and telestroke infrastructure, processes, and implementation strategies. The survey included both closed-ended and open-ended response options. Descriptive results are presented, complemented with illustrative examples of open-ended responses. Results: We received 89 responses, each representing a different hospital. Approximately one-third of telestroke programs in our sample began between 2018 and 2020. More than two-thirds reported participating in a collaboration with other organizations to improve telestroke services. The most commonly reported, high-priority topics for additional guidance involved monitoring process measures, using performance indicators for improvement, and sharing data from measures with physicians. Discussion: Results complement prior studies, specifically about impacts of COVID-19 on telestroke programs and capabilities that hospitals most need assistance with. Challenges faced and guidance needed differ across hospitals, suggesting a need for a tailored support. The results also suggest more work is needed to understand factors that threaten sustainability of telestroke programs.

Association of Financial Factors and Telemedicine Adoption for Heart Attack and Stroke Care Among Rural and Urban Hospitals: A Longitudinal Study.

Introduction: To examine trends in telemedicine adoption for stroke and cardiac care among U.S. hospitals, specifically associations between hospital financial indicators and adoption of these telemedicine services. Methods: This is a retrospective analysis of data from the Health Information Management and System Society Dorenfest Database and Healthcare Cost Report Information System from 2012 to 2017. We used a pooled ordinary least squares model and reported results as average marginal effects (AMEs). Results: The number of hospitals with stroke or cardiac telemedicine services in urban and rural areas increased through our study period from 153 (7.30%) to 407 (19.42%) and from 127 (6.31%) to 331 (16.45%), respectively. In rural hospitals, being a for-profit hospital (AME = -10.49, 95% confidence interval [CI] = -14.01 to -6.98) and having an increase in Medicare inpatient mix (AME = -0.31, 95% CI = -0.42 to -0.20) were associated with the probability of telemedicine adoption for heart attack and stroke care. A couple of nonfinancial variables included in the model also were associated with adoption, specifically having one more licensed bed (AME = -0.02, 95% CI = -0.04 to -0.00) and higher number of emergency department visits (AME = 5.64, 95% CI = 2.83 to 7.20). In urban hospitals, being a for-profit hospital (AME = -8.94, 95% CI = -11.76 to -6.11) and having a higher total margin (AME = 0.17, 95% CI = 0.08 to 0.26) were associated with the probability of telemedicine adoption for heart attack and stroke care. Two nonfinancial variables also were statistically significant: having one more licensed bed (AME = 0.01, 95% CI = 0.041 to 0.02) and being closer to another telemedicine hospital (AME = 0.81, 95% CI = -1.62 to 0.01). Discussions: Telemedicine adoption rate for cardiac and stroke care has increased significantly in recent years. Financial status may be a bigger driver of adoption for urban hospitals than rural hospitals.

Implementation Strategies for Telestroke: A Qualitative Study of Telestroke Networks in North Carolina.

Background: Telestroke services allow under-resourced hospitals to gain access to stroke specialists to improve the timeliness and quality of stroke care. However, limited research is available on how telestroke networks are developed, implemented, and sustained. Understanding the process of telestroke network implementation is critical for developing implementation guidance and for evaluating determinants of implementation effectiveness. Objective: This study examines the adoption decision process and strategies employed during telestroke network development, implementation, and sustainability. Research Design: We interviewed representatives from five telestroke networks in North Carolina. Each network consisted of a distant site from which stroke consultation was provided and multiple originating sites at which the patient presented. Subjects: The sample included 24 telestroke representatives (i.e., 5 network representatives and 19 hospital representatives) and 4 hospital representatives who do not participate in telestroke (i.e., nonadopters). Measures: The qualitative measures used in this study were based on Roger's stages of the innovation process in organizations. Stages included agenda setting and matching (pre-implementation), restructuring, redefining, and clarifying (implementation), and routinizing (sustainability). Results: Distant and originating sites employed various strategies in the pre-implementation, implementation, and sustainability stages. Although there are many commonalities across networks, there are also important differences, for example in terms of network structure, quality monitoring, and performance feedback. Some nonadopter hospitals reported difficulty accessing information about telestroke, suggesting that some hospitals are not reached by telestroke network marketing efforts. Conclusions: Identifying and/or tailoring strategies to support the needs of hospitals in different telestroke network models should be a priority for future research.

Telestroke Adoption Among Community Hospitals in North Carolina: A Cross-Sectional Study.

OBJECTIVE: This study identifies community and hospital characteristics associated with adoption of telestroke among acute care hospitals in North Carolina (NC). METHODS: Our sample included 107 hospitals located in NC. Our analytic dataset included variables from the American Hospital Association (AHA) annual survey, AHA Health IT supplement, Healthcare Cost Report Information System, and Centers for Disease Control and Prevention's WONDER online database. We supplemented our secondary sources with data on telestroke adoption and market-level variables developed for NC. We used the Consolidated Framework for Implementation Research and previous telehealth studies to guide selection of variables. We conducted a multivariate logistic regression to determine associations with telestroke adoption. RESULTS: Proportion of discharges that are Medicare (odds ratio [OR] = 1.93, P < .04) and total operating margin (OR = 2.89, P = .00) were positively associated with telestroke adoption. Critical access hospital status was positively associated with telestroke adoption, although not at P < .05 (OR = 5.61, P = .07). Distance to the nearest hospital with a telestroke program (OR = .91, P = .01) and volume of emergency department visits (OR = .98, P < .05) were both negatively associated with telestroke adoption. CONCLUSIONS: Our study is novel in its focus on telestroke adoption and use of variables not included in previous telehealth analyses. Our findings suggest some hospitals have neither the financial resources nor the ability to pool resources for acquiring needed technology, and differences in adoption may result in geographic inequities in access to telestroke services.

Urban-Rural Differences in School Nurses' Asthma Training Needs and Access to Asthma Resources.

PURPOSE: Few studies have examined school nurses preferences' for asthma training. Our purpose was to: 1) assess school nurses' perceived asthma training needs, 2) describe nurses' access to asthma educational resources, and 3) identify urban-rural differences in training needs and access to resources in southern states. DESIGN AND METHODS: A convenience sample of school nurses (n=162) from seven counties (two urban and five rural) in North Carolina and South Carolina completed an online, anonymous survey. Chi-square tests were used to examine urban-rural differences. RESULTS: Although most nurses (64%) had received asthma training within the last five years, urban nurses were more likely to have had asthma training than rural nurses (χ2=10.84, p=0.001). A majority of nurses (87%) indicated they would like to receive additional asthma training. Approximately half (45%) of nurses reported access to age-appropriate asthma education materials, but only 16% reported that their schools implemented asthma education programs. Urban nurses were more likely than rural nurses to have access to asthma education programs (χ2=4.10, p=0.04) and age-appropriate asthma education materials (χ2=8.86, p=0.003). CONCLUSIONS: Few schools are implementing asthma education programs. Rural nurses may be disadvantaged in terms of receiving asthma training and having access to asthma education programs and materials. PRACTICE IMPLICATIONS: Schools are an ideal setting for delivering age-appropriate asthma education. By providing school nurses with access to age-appropriate asthma education resources and additional asthma training, we can help them overcome several of the barriers that impede their ability to deliver asthma care to their students.

Partnering with middle school students to design text messages about HPV vaccination.

Human papillomavirus (HPV) vaccination is routinely recommended for U.S. adolescents ages 11 to 12 years, yet vaccine coverage remains low. Text message HPV immunization reminders to parents have been effective with increasing uptake, but text messages directly to adolescents in order to increase HPV vaccination uptake are unknown. The purpose of this study was to examine the acceptability of text messages about HPV vaccination and message preferences among adolescents. Middle school students (n = 43) assisted in designing text messages to promote HPV vaccine among their peers. Through seven focus groups and two in-class surveys, we assessed students' knowledge of HPV vaccine, use of texting, and preferences for text messages and sources. The average age of participants was 13 years, and all were White (17 males, 26 females) in this rural setting. More than 70% used text messaging with a cell phone. The text message with the best composite score (M = 2.33, SD = 0.72) for likeability, trustworthiness, and motivation to seek more information was a gain frame emphasizing reduction in HPV infection if vaccinated against HPV. Text messages with lower scores emphasized threats of disease if not vaccinated. Participants (68%) preferred doctors as their information source. Text messaging to adolescents may be a strategy to improve HPV knowledge and vaccination.

Innovative Strategies for Addressing Adolescent Health in Primary Care Through Telehealth.

With recent gains in telehealth access across health sectors, this editorial explores adolescent-specific health issues where innovative use of virtual care is improving outcomes and access for adolescents. These include contraception, obesity, gender-affirming care, mental health, and eating disorder care. Clinicians caring for adolescents should be aware of advances in this field to maximize opportunities for their patients to receive evidence-based care in a manner that supports health equity and confidentiality concerns while understanding the evolving regulatory landscape of telehealth.

Expanding Telehealth in Adolescent Care: Moving Beyond the COVID-19 Pandemic.

Telehealth use has expanded dramatically through the coronavirus disease 2019 pandemic, allowing improved access and convenience for many patients. Before coronavirus disease 2019, there was limited research on the use of telehealth to reach adolescents. During the pandemic, research revealed that adolescents and their parents felt telehealth was convenient and provided confidential, high-quality care. As the use of telehealth to reach adolescents evolves in the postpandemic period, medical providers have the opportunity to transform how care is delivered to adolescents but must strive to ensure that the care is designed to decrease digital health inequities and provide coordinated care.

Exploring community members' perceptions to adopt a Tele-COPD program in rural counties.

Background: Patients diagnosed with COPD residing in rural areas report a lower quality of life. Telehealth addresses geographic barriers by offering routine, technology-based visits, and remote patient monitoring. Objective: The study objective was to explore adoption perceptions of a tele-COPD program among community members in rural Western North Carolina (WNC) counties. Methods: A convenience sample of 17 community members were recruited to participate in one of five 45-min focus groups. Before the focus group, all participants completed a brief demographic survey. Focus groups were digitally recorded, transcribed verbatim, imported into MAXQDA v10, and analyzed thematically using established qualitative coding procedures. SPSS v22 was used to calculate descriptive statistics. Results: Participants were primarily Non-Hispanic White (100%), male (59%), insured (100%), and had at least a high school education (80%). Only 25% of participants had any prior knowledge of telehealth programs. The majority (94%) of participants expressed interest in receiving a tele-COPD program due to convenience factors. Yet, most participants expressed a lack of interest and comfort in using Internet-capable devices (e.g., mobile devices, tablets, computers). Participants noted that to be successful, telehealth visits must be described and shown to them by their own provider or other trusted individual(s), such as a pharmacist. Privacy and cost were also expressed as telehealth concerns. Conclusion: Interest in a tele-COPD program was high among community residents in rural WNC. However, to increase patient willingness to adopt a tele-COPD program, patients' providers must overcome challenges, such as patients' awareness and knowledge of telehealth, privacy and cost concerns, and access to and comfort with using new technologies. Pharmacists may mitigate these challenges by increasing patients' trust and comfort with telehealth programs.

School-Based Health Care.

School-based health care encompasses a variety of health care professionals and practice models, including school nursing, school-based health centers, and school-based mental health programs. Services can be delivered in person or via telehealth. School-based health care is an important mechanism for removing barriers to health care services and for reaching adolescent patients. This article illustrates the various models of school-based health care, the particular benefit of school-based health care for adolescents, and opportunities and challenges in maintaining and sustaining a school-based health program.