Parent, Physician, and Therapist Experience of In-Person, Hybrid, and All-Virtual Models of Physiatry Care for Children with Special Health Care Needs.

OBJECTIVE: The purpose of this study was to compare three models of pediatric physiatry care (in-person, hybrid, and all-virtual) in terms of parent experience and physician- and therapist-reported quality of care. We hypothesized that the all-virtual model would have lower parent experience scores and lower quality scores compared with the other two models of care. METHODS: We designed a convergent parallel mixed methods study incorporating a cluster-randomized crossover design. Quantitative data included surveys of parents, physicians, and therapists after visits to 13 medical therapy units in Northern California between January 2020 and January 2022. Qualitative data were collected in six focus groups with parents, physicians, and therapists. RESULTS: A total of 2455 visits were completed for 1281 unique children during the study period, including 507 in-person visits, 246 hybrid visits, and 1702 all-virtual visits. There were no differences in parent experience scores between the three models of care. Physicians and therapists rated all-virtual visits significantly lower in terms of quality of care, parent education, and physical exam, compared with the other two models of care, but qualitative results highlighted specific instances where all-virtual visits could be useful. CONCLUSIONS: Our findings suggest that parents, therapists, and physicians find a hybrid virtual model is an acceptable model of care that maintains the quality of care and facilitates parent education. All-virtual models may be appropriate for specific circumstances but are perceived as lower quality. Research exploring implementation of these models would be valuable for providing practical guidance in the future.

Adapting telehealth to address health equity: Perspectives of primary care providers across the United States.

BACKGROUND: Telehealth has the potential to increase access to care for medically underserved patients. This qualitative study aimed to identify telecare practices used during the COVID-19 pandemic to meet the needs of patients experiencing homelessness, patients with disabilities, and patients with language preference other than English (LOE). METHODS: We conducted a secondary qualitative data analysis of 47 clinician interviews at Federally Qualified Health Centers (FQHCs) around the country. Using thematic analysis, transcripts were coded by line-by-line by five qualitative researchers. A multidisciplinary team of telehealth experts, researchers and primary care clinicians reviewed memos and excerpts to generate major themes. RESULTS: We identified six main areas demonstrating how community providers developed strategies or practices to improve access to care for vulnerable patients: reaching patients experiencing homelessness, serving deaf and hard of hearing patients, improving access for patients with disabilities, serving patients with LOE, improving access for mental and behavioral health services, and educating patients about telehealth. During the pandemic, FQHCs developed innovative solutions to provide access to care for the unhoused, including using telehealth in shelters, vans, and distributing devices like mobile phones and tablets. Telehealth reduced transportation burdens for patients with disabilities and reduced no-show rates for mental health services by adapting group therapy via telehealth features (like break-out rooms) and increasing provider capacity. CONCLUSION: Our study identified strategies adopted by FQHCs to serve underserved populations during the COVID-19 pandemic. Our findings highlight the need for enduring strategies to improve health equity through telehealth..

Telemedicine vs Telephone Consultations and Medication Prescribing Errors Among Referring Physicians: A Cluster Randomized Crossover Trial.

Importance: Critically ill children presenting to emergency departments (EDs) in non-children's hospitals are at high risk for experiencing medical errors, including medication errors. Video telemedicine consultations with pediatric specialists have the potential to reduce the risk of medication errors beyond the current standard of care, telephone consultations. Objective: To compare the rates of ED physician-related medication errors among critically ill children randomized to receive either video telemedicine or telephone consultations. Design, Setting, and Participants: This cluster randomized, unbalanced crossover trial was conducted at 15 community EDs in northern California between September 2014 and March 2018. Analyses were conducted from May 2022 to January 2023. Participants included acutely ill children younger than 15 years presenting to a participating ED. Interventions: Participating EDs were randomized to use video telemedicine or telephone for consultations with pediatric critical care physicians according to 1 of 4 unbalanced (3 telemedicine to 1 telephone) crossover treatment assignment sequences. Main Outcomes and Measures: Pharmacists reviewed medical records to document physician-related medication errors using a previously validated instrument. Multilevel logistic regression analyses were performed to create models with the medication order as the unit of analysis and adjusting for age, the log-transformed Revised Pediatric Emergency Assessment Tool score, and hospital study period. Results: A total of 696 patient encounters were included in the trial (mean [SD] age, 4.2 [4.6] years; median [IQR] age, 2.1 [0.5-2.1] years; 304 female [43.7%]), with 537 patient encounters (77.2%) assigned to video telemedicine and 159 patient encounters (22.8%) assigned to telephone. At least 1 physician-related medication error occurred for 87 patients (12.5%), including 20 of 159 patients (12.6%) in the telephone cohort and 67 of 537 patients (12.5%) in the telemedicine cohort. Of the 2414 medication orders, errors occurred in 124 cases (5.1%), including 26 of 513 orders (5.1%) in the telephone cohort and 98 of 1901 orders (5.2%) in the telemedicine cohort. In the multivariable analysis, the adjusted odds ratio of experiencing a medication error among those assigned to telemedicine was 0.86 (95% CI, 0.49-1.52; P = .61). Conclusions and Relevance: This cluster randomized crossover trial found no statistically significant differences in physician-related medication errors between critically ill children assigned to receive telephone consultations vs video telemedicine consultations. Trial Registration: ClinicalTrials.gov Identifier: NCT02877810.