Development and evaluation of a clinical guideline for a paediatric telemedicine service in a low-resource setting.

OBJECTIVE: To develop and evaluate a guideline for a paediatric telemedicine and medication delivery service (TMDS). METHODS: A clinical guideline for paediatric telemedicine was derived from the World Health (WHO) Organization Integrated Management of Childhood Illness (IMCI) Handbook. The guideline was deployed at a TMDS in Haiti and evaluated through a prospective cohort study; children ≤10 years were enrolled. For non-severe cases, paired virtual and in-person examinations were conducted at the call centre and household; severe cases were referred to the hospital. The performance of virtual examination components were evaluated by comparison with the paired in-person examination findings (reference). RESULTS: A total of 391 cases were enrolled. Among the 320 cases with paired examinations, no general WHO danger signs were identified during in-person examinations; 5 cases (2%) required hospital referral due to problem-specific danger signs or other reasons for escalation. Cohen's kappa for the virtual designation of mild cases was 0.78 (95% CI: 0.69 to 0.87). The sensitivity and specificity of a virtually reported fever were 91% (95% CI: 87% to 96%) and 69% (95% CI: 62% to 76%), respectively; the sensitivity and specificity of virtually reported 'fast breathing' were 47% (95% CI: 21% to 72%) and 89% (95% CI: 85% to 94%), respectively. Kappa for 'no' and 'some' dehydration indicated moderate congruence between virtual and in-person examinations (0.69; 95% CI: 0.41 to 0.98). At 10 days, 273 (95%) of the 287 cases reached by phone were better/recovered. CONCLUSION: Critical components of the virtual examination (triage, danger signs and dehydration assessment) performed well despite varied performance among the problem-specific components. The study and associated resources represents formative steps towards an evidence-based paediatric telemedicine guideline built on WHO clinical principles. In-person examinations for select cases were important to address limitations with virtual examinations and identify cases for escalation. TRIAL REGISTRATION NUMBER: NCT03943654.

Implementation of a Pediatric Telemedicine and Medication Delivery Service in a Resource-limited Setting: A Pilot Study for Clinical Safety and Feasibility.

OBJECTIVE: Determine the clinical safety and feasibility of implementing a telemedicine and medication delivery service (TMDS) to address gaps in nighttime access to health care for children in low-resource settings. STUDY DESIGN: We implemented a TMDS called 'MotoMeds' in Haiti as a prospective cohort study. A parent/guardian of a sick child ≤ 10 years contacted the call center (6 PM-5 AM). A nurse provider used decision support tools to triage cases (mild, moderate, or severe). Severe cases were referred to emergency care. For nonsevere cases, providers gathered clinical findings to generate an assessment and plan. For cases within the delivery zone, a provider and driver were dispatched and the provider performed a paired in-person exam as a reference standard for the virtual call center exam. Families received a follow-up call at 10 days. Data were analyzed for clinical safety and feasibility. RESULTS: A total of 391 cases were enrolled from September 9, 2019, to January 19, 2021. Most cases were nonsevere (92%; 361); household visits were completed for 89% (347) of these cases. Among the 30 severe cases, 67% (20) sought referred care. Among all cases, respiratory problems were the most common complaint (63%; 246). At 10 days, 95% (329) of parents reported their child had "improved" or "recovered". Overall, 99% (344) rated the TMDS as "good" or "great". The median phone consultation time was 20 minutes, time to household arrival was 73 minutes, and total case time was 114 minutes. CONCLUSION: The TMDS was a feasible health care delivery model. Although many cases were likely self-limiting, the TMDS was associated with high rates of reported improvement in clinical status at 10 days. TRIAL REGISTRATION: clinicaltrials.gov: NCT03943654.

Aggressive Giant Cell Tumor of the Scapula in a 35-Year-Old Woman.

Giant cell tumors (GCTs) are a category of benign but locally aggressive tumors that are challenging to treat. GCT topography most often affects the epiphyseal and metaphyseal regions of long bones but rarely flat bones. We report the case of a 35-year-old woman with an aggressive GCT of the right scapula. Unfortunately, the late presentation of this case to the emergency department makes the scapulectomy more difficult to carry out effectively. As this case highlights, the lack of access to primary care and the lack of available family physicians in the community remains detrimental to good medical care in systems with limited resources.

A Nighttime Telemedicine and Medication Delivery Service to Avert Pediatric Emergencies in Haiti: An Exploratory Cost-Effectiveness Analysis.

We sought to compare the costs of a nighttime pediatric telemedicine and medication delivery service per disability-adjusted life year (DALY) averted to the costs of current hospital emergency care per DALY averted from a societal perspective. We studied a nighttime pediatric telemedicine and medication delivery service and hospital emergency care in a semi-urban and rural region of Haiti. Costs of the two services were enumerated to represent the financial investments of both providers and patients. DALYs averted were calculated to represent the "years lives lost" and "years lost to disability" from diarrheal, respiratory, and skin (bacterial and scabies etiologies) disease among children from 0 to 9 years old. The incremental cost-effectiveness ratio was estimated and compared with the per capita gross domestic product (GDP) of Haiti ($1,177). Cost-effectiveness was defined as an incremental cost-effectiveness less than three times the per capita GDP of Haiti ($3,531). The total costs of the nighttime telemedicine and medication delivery service and hospital emergency care to society were $317,898 per year and $89,392 per year, respectively. The DALYs averted by the service and hospital emergency care were 199.76 and 22.37, respectively. Correspondingly, the incremental cost-effectiveness ratio is estimated at $1,288 signifying the service costs an additional $1,288 to avert one additional DALY. A scaled nighttime pediatric telemedicine and medication delivery service is likely a cost-effective alternative to hospital emergency care for preemergency pediatric conditions in Haiti, and possibly in similar lower-middle-income countries.