Provider-to-provider telemedicine for sepsis is used less frequently in communities with high social vulnerability.

PURPOSE: Sepsis disproportionately affects patients in rural and socially vulnerable communities. A promising strategy to address this disparity is provider-to-provider emergency department (ED)-based telehealth consultation (tele-ED). The objective of this study was to determine if county-level social vulnerability index (SVI) was associated with tele-ED use for sepsis and, if so, which SVI elements were most strongly associated. METHODS: We used data from the TELEmedicine as a Virtual Intervention for Sepsis in Rural Emergency Department study. The primary exposures were SVI aggregate and component scores. We used multivariable generalized estimating equations to model the association between SVI and tele-ED use. FINDINGS: Our study cohort included 1191 patients treated in 23 Midwestern rural EDs between August 2016 and June 2019, of whom 326 (27.4%) were treated with tele-ED. Providers in counties with a high SVI were less likely to use tele-ED (adjusted odds ratio [aOR] = 0.51, 95% confidence interval [CI] 0.31‒0.87), an effect principally attributable to the housing type and transportation component of SVI (aOR = 0.44, 95% CI 0.22-0.89). Providers who treated fewer sepsis patients (1‒10 vs. 31+ over study period) and therefore may have been less experienced in sepsis care, were more likely to activate tele-ED (aOR = 3.91, 95% CI 2.08‒7.38). CONCLUSIONS: Tele-ED use for sepsis was lower in socially vulnerable counties and higher among providers who treated fewer sepsis patients. These findings suggest that while tele-ED increases access to specialized care, it may not completely ameliorate sepsis disparities due to its less frequent use in socially vulnerable communities.

Provider-to-provider telehealth for sepsis patients in a cohort of rural emergency departments.

BACKGROUND: Telehealth has been proposed as one strategy to improve the quality of time-sensitive sepsis care in rural emergency departments (EDs). The purpose of this study was to measure the association between telehealth-supplemented ED (tele-ED) care, health care costs, and clinical outcomes among patients with sepsis in rural EDs. METHODS: Cohort study using Medicare fee-for-service claims data for beneficiaries treated for sepsis in rural EDs between February 1, 2017, and September 30, 2019. Our primary hospital-level analysis used multivariable generalized estimating equations to measure the association between treatment in a tele-ED-capable hospital and 30-day total costs of care. In our supporting secondary analysis, we conducted a propensity-matched analysis of patients who used tele-ED with matched controls from non-tele-ED-capable hospitals. Our primary outcome was total health care payments among index hospitalized patients between the index ED visit and 30 days after hospital discharge, and our secondary outcomes included hospital mortality, hospital length of stay, 90-day mortality, 28-day hospital-free days, and 30-day inpatient readmissions. RESULTS: In our primary analysis, sepsis patients in tele-ED-capable hospitals had 6.7% higher (95% confidence interval [CI] 2.1%-11.5%) total health care costs compared to those in non-tele-ED-capable hospitals. In our propensity-matched patient-level analysis, total health care costs were 23% higher (95% CI 16.5%-30.4%) in tele-ED cases than matched non-tele-ED controls. Clinical outcomes were similar. CONCLUSIONS: Tele-ED capability in a mature rural tele-ED network was not associated with decreased health care costs or improved clinical outcomes. Future work is needed to reduce rural-urban sepsis care disparities and formalize systems of regionalized care.

Evaluation of Telepsychiatry Services Implementation in Medical and Psychiatric Inpatient Settings: A Mixed-Methods Study.

Introduction: Telepsychiatry consultation for rural providers may help address local staffing needs while ensuring timely and appropriate care from behavioral health experts. The purpose of this study was to assess the implementation of a telepsychiatry consultation service within medical and psychiatry inpatient units of hospitals serving predominantly rural areas. Methods: A mixed-methods study with qualitative interviews of site personnel and quantitative assessment of electronic health record data was conducted across 6 facilities in 3 U.S. states between June 2019 and May 2021. We interviewed 15 health care professionals 6 months after telepsychiatry was implemented, and we identified emerging themes related to the inpatient telepsychiatry service implementation and utilization through an inductive qualitative analysis approach. We then applied the themes emerging from this study to existing implementation science theoretical frameworks. Results: Telepsychiatry consultation was utilized for 437 medical inpatient cases and 531 psychiatric inpatient units. Average encounters by site ranged from 1 to 20 per month. The three main domains from the qualitative assessment included the impact on the care process (the partnership between inpatient units and the telehealth hub, and logistical dynamics), the care provider (resource availability in inpatient units and changes in inpatient units' capability), and the patient (impact on patient safety and care). Discussion: Implementation of a telepsychiatry service in the inpatient setting holds the promise of being beneficial to the patient, local hospital, and the rural community. In this study, we found that implementing this telepsychiatry service improved the clinical care processes, while addressing both the providers' and patients' needs.

Telehealth Services for Primary Care and Urgent Care to Support Rural Schools and Students.

Background: School-based health services, particularly those available to underserved and rural communities, remain in high demand. Advancements in telehealth services present clinical resources otherwise typically unavailable to students from rural communities. Methods: Data were collected during 4 semesters on all students receiving primary care or urgent care health services from 8 school-based telehealth programs delivering care to 40 schools across the United States. Results: Across the 4 semesters, 2,769 students received primary care telehealth and 2,238 students received urgent care telehealth. The primary care telehealth services were delivered by a primary care provider with a registered nurse also involved in half of the encounters. In contrast, the urgent care telehealth services were delivered almost exclusively by a registered nurse. Primary care telehealth delivered a variety of services including medication management, counseling, and sports physicals in addition to assessments and evaluations. Urgent care telehealth primarily involved an assessment. Both services returned most students to the classroom without the need for further follow-up, thus reducing or eliminating the need for seeking health care outside of the school setting. Notably, 67.7% of students seeking primary care telehealth services did not have a primary care provider outside of the school, clearly demonstrating the importance of these school-based services in increasing access to basic health care services for these students in rural and underserved communities. Conclusions: Telehealth provides a reliable solution and immediate access to care for students in need of health care, which, in turn, presents advantages to educators and parents.

Telepsychiatry services across an emergency department network: A mixed methods study of the implementation process.

BACKGROUND: Due to limited community resources for mental health and long travel distances, emergency departments (EDs) serve as the safety net for many rural residents facing crisis mental health care. In 2019, The Leona M. and Harry B. Helmsley Charitable Trust funded a project to establish and implement an ED-based telepsychiatry service for patients with mental health issues in underserved areas. The purpose of this study was to evaluate the implementation of this novel ED-based telepsychiatry service. METHODS: This was a mixed-methods study evaluating the new ED-based telepsychiatry consult service implemented in five EDs across three rural states that participated within a mature hub-and-spoke telemedicine network between June 2019 and December 2020. Quantitative evaluation in this study included characteristics of the telehealth encounters and the patient population for whom this service was used. For qualitative assessments, we identified key themes from interviews with key informants at the ED spokes to assess overall facilitators, barriers, and impact. Integrating the quantitative and qualitative findings, we explored emergent phenomena and identified insights to provide a comprehensive perspective of the implementation process. RESULTS: There were 4130 encounters for 3932 patients from the EDs during the evaluation period. Approximately 54% of encounters involved female patients. The majority of patients seen were white (51%) or Native American (44%) reflecting the population of the communities where the EDs were located. Among the indications for the telepsychiatry consult, the most frequently identified were depression (28%), suicide/self-harm (17%), and schizophrenia (12%). Across sites, 99% of clinician-to-clinician consults were by phone, and 99% of clinical assessments/evaluations were by video. The distribution of encounters varied by the day of the week and the time of day. Facilitators for the service included increasing need, a supportive infrastructure, a straightforward process, familiarity with telemedicine, and a collaborative relationship. Barriers identified by respondents at the sites included the lack of clarity of process and technical limitations. The themes emerging from the impact of the telepsychiatry consultation in the ED included workforce improvement, care improvement, patient satisfaction, cost-benefit, facilitating COVID care, and access improvement. CONCLUSIONS: Implementation of a telepsychiatry service in ED settings may be beneficial to the patient, local ED, and the underserved community. In this study, we found that implementing this service alleviated the burden of care during the COVID-19 pandemic, enhanced local site capability, and improved local ability to provide quality and effective care.

An economic and health outcome evaluation of telehealth in rural sepsis care: a comparative effectiveness study.

Aim: Sepsis is a top contributor to in-hospital mortality and, healthcare expenditures and telehealth have been shown to improve short-term sepsis care in rural hospitals. This study will evaluate the effect of provider-to-provider video telehealth in rural emergency departments (EDs) on healthcare costs and long-term outcomes for sepsis patients. Materials & methods: We will use Medicare administrative claims to compare total healthcare expenditures, mortality, length-of-stay, readmissions, and category-specific costs between telehealth-subscribing and control hospitals. Results: The results of this work will demonstrate the extent to which telehealth use is associated with total healthcare expenditures for sepsis care. Conclusion: These findings will be important to inform future policy initiatives to improve sepsis care in rural EDs. Clinical Trial Registration: NCT05072145 (ClinicalTrials.gov).

Sepsis is a severe condition that results from infection. In addition to costly care, sepsis is a leading cause of death and disability. When comparing outcomes, those treated for sepsis in lower volume emergency departments fare worse and rural emergency departments often have lower patient volumes. While telehealth has been shown to improve sepsis care, the effect of telehealth on costs and long-term outcomes for patients is unclear. This study will use Medicare claims data to compare outcomes for people with sepsis in rural emergency departments who had video telehealth used with those who did not have video telehealth used, with the goal of measuring how telehealth affects healthcare costs, hospital readmissions and deaths after hospital discharge.

TELEmedicine as an intervention for sepsis in emergency departments: a multicenter, comparative effectiveness study (TELEvISED Study).

Sepsis is a life-threatening infection that affects over 1.7 million Americans annually. Low-volume rural hospitals have worse sepsis outcomes, and emergency department (ED)-based telemedicine (tele-ED) has been one promising strategy for improving rural sepsis care. The objective of this study is to evaluate the impact of tele-ED consultation on sepsis care and outcomes in rural ED patients. The TELEvISED study is a multicenter (n = 25) retrospective propensity-matched comparative effectiveness study of tele-ED care for rural sepsis patients in a mature tele-ED network. Telemedicine-exposed patients will be matched with non telemedicine patients using a propensity score to predict tele-ED use. The primary outcome is 28-day hospital free days, and secondary outcomes include adherence with guidelines, mortality and organ failure. ClinicalTrials.gov: NCT04441944.

Home Environment, But Not Socioeconomic Status, is Linked to Differences in Early Phonetic Perception Ability.

Infants perceptually tune to the phonemes of their native languages in the first year of life, thereby losing the ability to discriminate non-native phonemes. Infants who perceptually tune earlier have been shown to develop stronger language skills later in childhood. We hypothesized that socioeconomic disparities, which have been associated with differences in the quality and quantity of language in the home, would contribute to individual differences in phonetic discrimination. Seventy-five infants were assessed on measures of phonetic discrimination at 9 months, on the quality of the home environment at 15 months, and on language abilities at both ages. Phonetic discrimination did not vary according to socioeconomic status (SES), but was significantly associated with the quality of the home environment. This association persisted when controlling for 9-month expressive language abilities, rendering it less likely that infants with better expressive language skills were simply engendering higher quality home interactions. This suggests that infants from linguistically richer home environments may be more tuned to their native language and therefore less able to discriminate non-native contrasts at 9 months relative to infants whose home environments are less responsive. These findings indicate that home language environments may be more critical than SES in contributing to early language perception, with possible implications for language development more broadly.

Socioeconomic disparities in neurocognitive development in the first two years of life.

Socioeconomic status (SES) is strongly associated with cognition and achievement. Socioeconomic disparities in language and memory skills have been reported from elementary school through adolescence. Less is known about the extent to which such disparities emerge in infancy. Here, 179 infants from socioeconomically diverse families were recruited. Using a cohort-sequential design, 90 infants were followed at 9 and 15 months, and 89 were followed at 15 and 21 months. SES disparities in developmental trajectories of language and memory were present such that, at 21 months of age, children of highly educated parents scored approximately .8 standard deviations higher in both language and memory than children of less educated parents. The home language and literacy environment and parental warmth partially accounted for disparities in language, but not memory development.