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.

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/.

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.

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.

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.

Time Required to Create a Referral in Various Store-and-Forward Telemedicine Networks.

Store and forward telemedicine is used routinely in health care, but there is little published information about how such telemedicine systems are used. For example, an important aspect of the system's usability is the length of time it takes to submit a referral. Referral-submission times were measured in networks based on the Collegium Telemedicus system. In a 25-week period in 2018/2019, eight Collegium networks received a total of 1,649 clinical or educational cases submitted via the web interface. The time to prepare a referral was measured in 669 of these cases, in two different ways. An indirect measurement of the referral-preparation time was calculated as the interval between the user logging in, and the referral being submitted. A direct measurement of the referral-preparation time was calculated as the interval between the user opening the referral page and the referral being submitted to the server. The difference between the two measurements represents time spent by the user on other activities after logging in, before beginning the referral. The median referral-preparation time, measured directly, was 888 s (IQR 512-1765). The median of the differences between the two preparation times was 27s (IQR 8-146). The referral-preparation times in the eight networks were broadly similar, despite the differences in the nature of their operation (clinical or educational), and the types of case handled (single specialty or multi-specialty). Quantitative information about aspects of the user interface, such as the referral-preparation time, is important not only in the initial system design, but also in its subsequent development.

Experience of Supporting Telemedicine Networks With the Collegium System: First 6 Years.

The Collegium system was first made available in 2012 to support organizations conducting humanitarian or non-commercial telemedicine work in low resource settings. It provides the technical infrastructure necessary to establish a store-and-forward telemedicine service. During the subsequent 6 years a total of 46 networks were established, based on the Collegium infrastructure. The majority of the networks were set up to provide a clinical service (33), with six designed for education and training, and the remainder for test or administrative purposes. Of the potentially operational networks which were set up (i.e., those established for clinical or educational purposes), 15 networks (38%) were stillborn and did not handle a single case after being established. In contrast, the two most active networks had handled almost 12,000 cases. The average case rate of the five most active clinical networks operating in low-resource settings (i.e., the total number of cases divided by the length of time for which the network had been established) ranged from 0.5 to 29.4 cases/week. Across the networks there was little evidence of sigmoidal growth in activity, which is consistent with reports of other telemedicine activity in North America. A brief survey was sent to 49 network coordinators, from 31 networks. Responses were received from 9 coordinators (18% of those invited to participate). The median satisfaction with the system was 8 (on a scale from 1 = not at all satisfied to 10 = very satisfied). The free text comments were mainly technical suggestions regarding image transfer, the mobile application, or other modes of communication. The results of operating the Collegium system demonstrate that supporting telemedicine work in low resource settings can be successful, since the networks handled a very wide range of clinical cases, and at activity levels up to several cases per day. However, approximately one-third of the networks that were established did not handle a single clinical case. Nonetheless, this might represent a form of success in the sense that it prevented the waste of resource involved in an organization purchasing a telemedicine infrastructure only to find that it was not used.

Telemedicine in Resource-Limited Settings to Optimize Care for Multidrug-Resistant Tuberculosis.

The emergence and spread of multidrug-resistant tuberculosis (MDR-TB) poses a major threat to the global targets for TB control. In recent years, an evolving science and evidence base for MDR-TB has led to much needed changes in international guidelines promoting the use of newer TB drugs and regimens for MDR-TB, however, there remains a significant implementation gap. Due to the complexity of treating MDR-TB, management of cases is often supported by an expert multidisciplinary team, or clinical expert group. This service is often centralized, and may be delivered through a telemedicine platform. We have implemented a Web-based "store-and-forward" telemedicine service to optimize MDR-TB patient care in Daru, a remote and resource limited setting in Papua New Guinea (PNG). From April 2016 to February 2019, 237 cases were discussed using the service. This encompassed diagnostic (presumptive) and treatment cases, and more recently, support to the scale up of preventative therapy for latent TB infection. There were 75 cases in which the use of Bedaquiline was discussed or mentioned, with a high frequency of discussions occurring in the initial period (26 cases in the first 12 months), which has appeared to decrease as clinicians gained familiarity with use of the drug (15 cases in the last 12 months). This service has supported high quality clinical care and fostered collaboration between clinicians and technical experts in a shared learning environment.

Seven years of telemedicine in Médecins Sans Frontières demonstrate that offering direct specialist expertise in the frontline brings clinical and educational value.

BACKGROUND: Médecins Sans Frontières (MSF), a medical humanitarian organization, began using store-and-forward telemedicine in 2010. The aim of the present study was to describe the experience of developing a telemedicine service in low-resource settings. METHODS: We studied the MSF telemedicine service during the period from 1st July 2010 until 30th June 2017. There were three consecutive phases in the development of the service, which we compared. We also examined the results of a quality assurance program which began in 2013. RESULTS: During the study period, a total of 5646 telemedicine cases were submitted. The workload increased steadily, and the median referral rate rose from 2 to 18 cases per week. The number of hospitals submitting cases and the number of cases per hospital also increased, as did the case complexity. Despite the increased workload, the allocation time reduced from 0.9 to 0.2 hours, and the median time to answer a case decreased from 20 to 5 hours. The quality assurance scores were stable. User feedback was generally positive and more than 90% of referrers who provided a progress report about their case stated that it had been sent to an appropriate specialist, that the response was sufficiently quick and that the teleconsultation provided an educational benefit. Referrers noted a positive impact of the system on patient outcome in 39% of cases. CONCLUSIONS: The quality of the telemedicine service was maintained despite rising caseloads. The study showed that offering direct specialist expertise in low-resource settings improved the management of patients and provided additional educational value to the field physicians, thus bringing further benefits to other patients.

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.

Reliability of an Online Geriatric Assessment Procedure Using the interRAI Acute Care Assessment System.

OBJECTIVES: To determine whether geriatric triage decisions made using a comprehensive geriatric assessment (CGA) performed online are less reliable than face-to-face (FTF) decisions. DESIGN: Multisite noninferiority prospective cohort study. Two specialist geriatricians assessed individuals sequentially referred for an acute care geriatric consultation. Participants were allocated to one FTF assessment and an additional assessment (FTF or online (OL)), creating two groups-two FTF (FTF-FTF, n = 81) or online and FTF (OL-FTF, n = 85). SETTING: Three acute care public hospitals in two Australian states. PARTICIPANTS: Admitted individuals referred for CGA. INTERVENTION: Nurse-administered CGA, based on the interRAI Acute Care assessment system accessed online and other online clinical data such as pathology results and imaging enabling geriatricians to review participants' information and provide input into their care from a distance. MEASUREMENTS: The primary decision subjected to this analysis was referral for permanent residential care. Geriatricians also recorded recommendations for referrals and variations for medication management and judgment regarding prognosis at discharge and after 3 months. RESULTS: Overall percentage agreement was 88% (n = 71) for the FTF-FTF group and 91% (n = 77) for the OL-FTF group. The difference in agreement between the FTF-FTF and OL-FTF groups was -3%, indicating that there was no difference between the methods of assessment. Judgements made regarding diagnoses of geriatric syndromes, medication management, and prognosis (with regard to hospital outcome and location at 3 months) were found to be equally reliable in each mode of consultation. CONCLUSION: Geriatric assessment performed online using a nurse-administered structured CGA system was no less reliable than conventional assessment in making clinical triage decisions.

Long-term exercise maintenance in COPD via telerehabilitation: a two-year pilot study.

Introduction Pulmonary rehabilitation (PR) is an integral part of the management of chronic obstructive pulmonary disease (COPD). However, many patients do not access or complete PR, and long-term exercise maintenance has been difficult to achieve after PR. This study aimed to investigate feasibility, long-term exercise maintenance, clinical effects, quality of life and use of hospital resources of a telerehabilitation intervention. Methods Ten patients with COPD were offered a two-year follow-up via telerehabilitation after attending PR. The intervention consisted of home exercise, telemonitoring and self-management via a webpage combined with weekly videoconferencing sessions. Equipment included a treadmill, a pulse oximeter and a tablet. Data collected at baseline, one year and two years were six-minute walking distance (6MWD), COPD assessment test (CAT), EuroQol 5 dimensions (EQ-5D), hospitalisations and outpatient visits. Results No dropout occurred. Physical performance, lung capacity, health status and quality of life were all maintained at two years. At one year, 6MWD improved by a mean of 40 metres from baseline, CAT decreased by four points and EQ visual analogue scale (EQ VAS) improved by 15.6 points. Discussion Long-term exercise maintenance in COPD via telerehabilitation is feasible. Results are encouraging and suggest that telerehabilitation can prevent deterioration and improve physical performance, health status and quality of life.

Web-based (online) comprehensive geriatric assessment is more time efficient, and as reliable, as reading patient medical records and conducting traditional in person consultations.

The aim of this study was to report the time taken by geriatricians to reach triage decisions using an online assessment format compared with face-to-face (FTF) assessment. Patients (N = 166) were randomly allocated to two groups: online and FTF assessments (OF group); and dual FTF assessments (FF group). Case preparation was conducted by trained nurse assessors using a web-enabled clinical decision support system. Geriatricians allocated to perform an 'online' assessment had access to this information only. Geriatricians allocated FTF assessments reviewed this data, as well as the paper-based medical file and then consulted directly with the patient and attending staff. Data were collected in relation to time taken to complete OL assessments, compared with FTF assessments. A complete OL consultation averages 10 minutes, and a FTF consultation almost 26 minutes. In FTF consultations, less time is spent using the OL material when the geriatrician is aware that they will have access to the patient chart and need time to speak with the patient. The less time taken using the OL approach did not significantly alter the triage decisions made by the geriatricians.

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.

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 .

User Feedback on the MSF Tele-Expertise Service After a 4-Year Pilot Trial - A Comprehensive Analysis.

We surveyed all users of the Médecins Sans Frontières (MSF) tele-expertise service, approximately four years after it began operation. The survey contained 50 questions and was sent to 294 referrers and 254 specialists. There were 163 responses (response rate 30%). There were no significant differences between the responses from French and English users, so the responses were combined for subsequent analysis. Most of the responders were doctors (133 of 157 who answered that question), and most had completed field missions for MSF, i.e., both specialists and referrers. The majority stated that the system was user friendly and that they found it self-explanatory (i.e., they did not need to be shown how to use it). Almost all the referrers found that the telemedicine advice that they received was helpful, changed diagnosis and management, and/or reassured the patient. Similar feedback came from the specialists, who also felt that there was educational value for the field doctor. Although there was general satisfaction with the service, the survey identified various problems. The main concerns of the referrers were the lack of promotion of the system at headquarters' level, and the main concerns of the specialists were the lack of feedback about patient follow-up. Nonetheless, both referrers and specialists recognized the benefits of telemedicine in improving patient management, providing education, and reducing isolation in the field.

Relationship between the Quality of Service Provided through Store-and-Forward Telemedicine Consultations and the Difficulty of the Cases - Implications for Long-Term Quality Assurance.

We examined the difficulty of telemedicine cases and the quality of the resultant consultation in a mature store-and-forward telemedicine network. A random sample of 10 telemedicine cases was selected from those occurring over a 3-month period (5% of the workload) and they were scored by three experienced observers. Inter-observer agreement on the difficulty scores was poor (Fleiss's kappa = 0.18) and it was also poor on the consultation quality scores (Fleiss's kappa = 0.11). Differences between observers were minimized by consensus scoring, and the cases were re-assessed jointly by two observers. Based on the consensus scores, there was a weak negative relation between output quality and case difficulty, i.e., the more difficult cases tended to result in lower quality consultations. However, the effect was non-significant (P = 0.59) and a larger study might be helpful. In the meantime, routine monitoring of telemedicine service quality will continue in the interests of quality assurance. As yet, there is no evidence on which to base a correction for case difficulty.

Experience with Quality Assurance in Two Store-and-Forward Telemedicine Networks.

Despite the increasing use of telemedicine around the world, little has been done to incorporate quality assurance (QA) into these operations. The purpose of the present study was to examine the feasibility of QA in store-and-forward teleconsulting using a previously published framework. During a 2-year study period, we examined the feasibility of using QA tools in two mature telemedicine networks [Médecins Sans Frontières (MSF) and New Zealand Teledermatology (NZT)]. The tools included performance reporting to assess trends, automated follow-up of patients to obtain outcomes data, automated surveying of referrers to obtain user feedback, and retrospective assessment of randomly selected cases to assess quality. In addition, the senior case coordinators in each network were responsible for identifying potential adverse events from email reports received from users. During the study period, there were 149 responses to the patient follow-up questions relating to the 1241 MSF cases (i.e., 12% of cases), and there were 271 responses to the follow-up questions relating to the 639 NZT cases (i.e., 42% of cases). The collection of user feedback reports was combined with the collection of patient follow-up data, thus producing the same response rates. The outcomes data suggested that the telemedicine advice proved useful for the referring doctor in the majority of cases and was likely to benefit the patient. The user feedback was overwhelmingly positive, over 90% of referrers in the two networks finding the advice received to be of educational benefit. The feedback also suggested that the teleconsultation had provided cost savings in about 20% of cases, either to the patient/family, or to the hospital/clinic treating the patient. Various problems were detected by regular monitoring, and certain adverse events were identified from email reports by the users. A single aberrant quality reading was detected by using a process control chart. The present study demonstrates that a QA program is feasible in store-and-forward telemedicine, and shows that it was useful in two different networks, because certain problems were detected (and then solved) that would not have been identified until much later. It seems likely that QA could be used much more widely in telemedicine generally to benefit patient care.