Evaluating the Impact of Teleconsultations on Access to Ambulatory Primary Care in Medically Underserved Areas: A National Observational Cross-Sectional Multicenter Study.

Introduction: Access to care is a major public health concern particularly in medically underserved areas (MUAs) (Zones d'Interventions Prioritaires). Teleconsultations were legalized in France in 2010, however, have been reimbursed by the national health insurance since 2018. Large-scale studies assessing the impact of teleconsultations on access to care are limited. The objective of this study was to evaluate the impact of teleconsultations in MUAs at a national scale. Methods: An observational, multicenter cross-sectional study was conducted in seven teleconsultation centers. Teleconsultations were included if they were with patients living in France and received ambulatory care at primary ambulatory care settings by registered medical doctors between August 1 and November 30, 2021. Each center provided a randomized sample of 3,000 case data per month, yielding a total of 84,000 patients. Teleconsultation incidence was measured in MUAs and non-MUAs as the primary outcome. Results: In total, 25.1% of French patients lived in MUAs, with a mean age of 30.1 ± 0.08 years. Incidence of teleconsultations was 1,964 per 100,000 compared with 787 per 100,000 in non-MUAs (p < 0.0001). Teleconsultations were mostly performed during the day (88.6%), on weekdays (90.6%), were booked (88.3%), involved a general practitioner (GP) (89.0%), and were carried out as a video consultation (96.5%). The median delay to access was 60 min for GPs. Discussion: This was the largest study of teleconsultations in France and the first in the world to pool data from competing telemedicine companies. The incidence of teleconsultations was higher in MUAs, which may show that teleconsultations improve access to care. Clinical Trial Registration number: NCT05311241.

Knowledge, attitudes and practices of telemedicine education and training of French medical students and residents.

INTRODUCTION: Telemedicine is a remote medical practice that is progressively expanding in France. In 2018, regulatory changes authorised telemedicine to become part of daily clinical practice. Telemedicine education and training (ET), however, has not been widespread, despite its integration in the medical curriculum since 2009. The objective of this study was to examine the self-perceived knowledge, attitudes and practices (KAP) and ET of telemedicine ET from medical students and residents in France. METHODS: A national survey was distributed online (15 December 2018 to 3 March 2019) to approximately 135,000 medical students and residents in medical schools (n = 38). The survey consisted of a total of 24 binary and Likert-scale questions covering telemedicine ET and KAP. RESULTS: In total, 3,312 medical students and residents completed the survey. Synchronous video consultation was the most well-known telemedicine activity (86.9%); asynchronous tele-expertise was the least recognised (40.3%). Most respondents (84.8%) stated they were not familiar with telemedicine regulations. The relevance of telemedicine for improving access to care was acknowledged by 82.8% of students and residents; 14% of respondents stated they had previously practised telemedicine during their studies; 14.5% stated they had received telemedicine ET; however, 97.9% stated they were not sufficiently trained. DISCUSSION: This is the first national scale study on telemedecine ET by medical students and residents, to date. Despite positive attitudes, participants were found to have limited telemedicine ET, knowledge and practices. The demand for telemedicine ET is increasing. Such studies that incorporate the perspectives of medical students and residents may strengthen the implementation of telemedicine ET in the future.

Motivations of French Physicians to Perform Teleconsultations During COVID-19: A Mixed-Method Study.

Background: Teleconsultations have been an indispensable part of the public health armamentarium during the COVID-19 crisis. Many physicians replaced face-to-face consultations with teleconsultations for the very first time. This study aimed to understand telemedicine uses by physicians during the lockdown period and explain the changes in their teleconsultation practices after the reopening of an outpatient department. Methods: A mixed-method analysis was used. First, a quantitative study was conducted with a retrospective analysis of the ratio of all teleconsultations and physical consultations between January 1 and July 31, 2020. Second, semidirective interviews were undertaken with physicians to better understand the dynamics of teleconsultation use. Results: In total, 28 physicians practiced 603 teleconsultations over the study period. The rate of teleconsultations was 0.2% before the lockdown (January 1 to March 15, 2020), reaching 19.5% during the lockdown (April 2020), and decreasing to 8.4% at the reopening of the physical outpatient facilities. Based on the dynamics of their teleconsultation uses, four medical departments were selected for the qualitative study component (neurology, urology, pneumology, and anesthesiology). From the semistructured interviews, the main uses of telemedicine were for patients living with "chronic but under control" conditions that received follow-ups. Physicians also identified practices to improve patient empowerment and nurse autonomy. The results of the anesthesiology department showed that teleconsultations must be more codified to meet the same standards of quality as face-to-face consultations. Conclusion: The COVID-19 outbreak and lockdown period triggered a wider use of teleconsultations and have allowed physicians to think about new uses and opportunities.

Recurrence Rate and Cost Consequence of the Shortage of Bacillus Calmette-Guérin Connaught Strain for Bladder Cancer Patients.

BACKGROUND: Between 2013 and 2016, global production of bacillus Calmette-Guérin (BCG) was dramatically reduced due to the collapse of the factory producing BCG Connaught. OBJECTIVE: To evaluate the clinical and economic impact of BCG shortage on a cohort of non-muscle-invasive bladder cancer (NMIBC) patients treated during the period of restricted supply. DESIGN, SETTING AND PARTICIPANTS: This retrospective, before and after, cost-consequence study included patients with intermediate- and high-risk NMIBC. Those resected between November 2011 and September 2013 (control group) were compared with those resected between October 2013 and December 2016 (study group). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary endpoint was the rate of tumor recurrence from 30 d after transurethral resection to the end of follow-up at 24 mo; the secondary endpoints included the average cost of primary treatment, average cost of treatment of recurrence, and excess cost due to BCG shortage per patient. RESULTS AND LIMITATIONS: A total of 402 patients were included: 191 in the control group and 211 in the study group. The rate of recurrence at 24 mo was significantly higher in the study group than in the control group (46.9% vs 16.2%; relative risk: 0.7, 95% confidence interval [0.60; 0.82]; p < 0.001). The increased cost due to the decrease in BCG production was estimated to be €783 per patient with a new diagnosis of NMIBC during the period of restricted supply. This is a retrospective analysis at the level of our unit. A more precise evaluation would require a study of a larger cohort of patients. CONCLUSIONS: The shortage of BCG between October 2013 and December 2016 had a significant medical and economic impact; there was an increased rate of bladder cancer recurrence, and the total cost of care for intermediate- and high-risk NMIBC was higher. PATIENT SUMMARY: In this report, we analyzed the medical and economic impact of bacillus Calmette-Guérin (BCG) shortage that occurred between 2013 and 2016. We found a significant increase of bladder cancer recurrence and progression, and an increase in the number of patients who had to be treated by cystectomy. BCG shortage also had a significant impact on the total cost. Since there are no alternatives to BCG for high-risk non-muscle-invasive bladder cancer patients, BCG production has to be maintained by any means.

Establishment of an internationally agreed minimum data set for acute telestroke.

INTRODUCTION: Globally, the use of telestroke programmes for acute care is expanding. Currently, a standardised set of variables for enabling reliable international comparisons of telestroke programmes does not exist. The aim of the study was to establish a consensus-based, minimum dataset for acute telestroke to enable the reliable comparison of programmes, clinical management and patient outcomes. METHODS: An initial scoping review of variables was conducted, supplemented by reaching out to colleagues leading some of these programmes in different countries. An international expert panel of clinicians, researchers and managers (n = 20) from the Australasia Pacific region, USA, UK and Europe was convened. A modified-Delphi technique was used to achieve consensus via online questionnaires, teleconferences and email. RESULTS: Overall, 533 variables were initially identified and harmonised into 159 variables for the expert panel to review. The final dataset included 110 variables covering three themes (service configuration, consultations, patient information) and 12 categories: (1) details about telestroke network/programme (n = 12), (2) details about initiating hospital (n = 10), (3) telestroke consultation (n = 17), (4) patient characteristics (n = 7), (5) presentation to hospital (n = 5), (6) general clinical care within first 24 hours (n = 10), (7) thrombolysis treatment (n = 10), (8) endovascular treatment (n = 13), (9) neurosurgery treatment (n = 8), (10) processes of care beyond 24 hours (n = 7), (11) discharge information (n = 5), (12) post-discharge and follow-up data (n = 6). DISCUSSION: The acute telestroke minimum dataset provides a recommended set of variables to systematically evaluate acute telestroke programmes in different countries. Adoption is recommended for new and existing services.

A novel personalized approach to cardiovascular prevention: The VIVOPTIM programme.

BACKGROUND: Cardiovascular diseases are a leading cause of mortality, but a substantial proportion are preventable. AIMS: The Mutuelle générale de l'éducation nationale (MGEN), a provider of private health insurance in France, has developed the VIVOPTIM programme, a novel digital approach to healthcare based on individualized, multiprofessional, ranked management of cardiovascular risk factors. METHODS: Between November 2015 and June 2016, eligible individuals (age 30-70 years) from two regions of France were invited to participate. Volunteers completed a questionnaire based on the Framingham Heart Study Risk Score and were assigned to one of three cardiovascular risk levels. VIVOPTIM comprises four components: cardiovascular risk assessment, instruction on cardiovascular diseases and associated risk factors, personalized coaching (telephone sessions with a specially trained healthcare professional to provide information on risk factors and disease management, set individual health targets, monitor progress and motivate participants), and e-Health monitoring. RESULTS: Data from 2240 participants were analysed. Significant benefits were observed on mean systolic blood pressure (-3.4mmHg), weight (-1.5kg), smoking (-2.2 cigarettes/day) and daily steps (+1726 steps/day (all P<0.0001)), though not on weekly duration of exercise (-0.2hours/week, P=0.619). CONCLUSION: As a result of the positive mid-to-long-term results of the pilot programme on weight, smoking, blood pressure, and uptake of physical activity, the VIVOPTIM programme was extend to the whole of France in 2018 and has the potential to have a genuine impact on patient care and organization of the healthcare system in France.

Global Telemedicine Implementation and Integration Within Health Systems to Fight the COVID-19 Pandemic: A Call to Action.

On March 11, 2020, the World Health Organization declared the coronavirus disease 2019 (COVID-19) outbreak as a pandemic, with over 720,000 cases reported in more than 203 countries as of 31 March. The response strategy included early diagnosis, patient isolation, symptomatic monitoring of contacts as well as suspected and confirmed cases, and public health quarantine. In this context, telemedicine, particularly video consultations, has been promoted and scaled up to reduce the risk of transmission, especially in the United Kingdom and the United States of America. Based on a literature review, the first conceptual framework for telemedicine implementation during outbreaks was published in 2015. An updated framework for telemedicine in the COVID-19 pandemic has been defined. This framework could be applied at a large scale to improve the national public health response. Most countries, however, lack a regulatory framework to authorize, integrate, and reimburse telemedicine services, including in emergency and outbreak situations. In this context, Italy does not include telemedicine in the essential levels of care granted to all citizens within the National Health Service, while France authorized, reimbursed, and actively promoted the use of telemedicine. Several challenges remain for the global use and integration of telemedicine into the public health response to COVID-19 and future outbreaks. All stakeholders are encouraged to address the challenges and collaborate to promote the safe and evidence-based use of telemedicine during the current pandemic and future outbreaks. For countries without integrated telemedicine in their national health care system, the COVID-19 pandemic is a call to adopt the necessary regulatory frameworks for supporting wide adoption of telemedicine.

National survey of telemedicine education and training in medical schools in France.

INTRODUCTION: Telemedicine is a remote medical practice using information communication technology (ICT), and has been increasing in France since 2009. With all new forms of medical practice, education and training (ET) is required for quality and safety. To date, implementation of telemedicine ET has not been assessed in France. The objective of this study was to describe the implementation of telemedicine ET and evaluate the knowledge, attitudes and practices (KAP) of deans and associate deans from all medical schools in France. METHODS: A cross-sectional non-mandatory, descriptive online survey with a self-administered questionnaire was performed from 15 November to 6 December, 2017. Respondents were accessed through the 'Conférence des doyens des Facultés de médecine'. RESULTS: There were 48 respondents with a 47.4% response rate among deans. Telemedicine ET was limited in France; 10.4% in 1st year medicine (PACES); 4% in the final 3 years of medical school (D.F.A.S.M.) and 18.8% in medical residency. Emergency medicine, dermatology, radiology, neurology and geriatrics were specialties with implemented telemedicine training during residency. Of all respondents, 90% expressed a need to increase telemedicine ET, among which 75% accepted external support. A highly positive attitude towards telemedicine practice was reflected by 60.4% of respondents, and 56.2% practiced telemedicine at least once. DISCUSSION: This study was the first to assess national telemedicine ET implementation in France. Telemedicine was integrated into initial medical education; however, telemedicine ET remains limited despite the positive attitudes of deans and associate deans. Further research would need to be conducted on telemedicine ET implementation and KAP of medical students and residents.

Health policy analysis of the non-implementation of HPV vaccination coverage in the pay for performance scheme in France.

Background: The French National Cancer Control Plan (NCCP) launched in 2014 set the objective to improve human papillomavirus (HPV) vaccination coverage (VC). The NCCP included a measure to integrate a VC indicator in the pay for performance (P4P) scheme for general practitioners (GPs), which was not implemented. The objective of the study was to analyse the reasons for non-implementation of this measure, using the health policy analysis framework. Methods: The policy from proposal to non-implementation of the HPV VC indicator into the P4P scheme was analysed through the actors involved, the content of the measure, the contextual factors and the processes of policy-making. Results: The actors were the Ministry of Health (MOH) and National Cancer Institute as policy-makers, the public health insurance as an indirect target, and GPs as direct targets. The content of the policy was not evidence-informed and was not included into the NCCP preparation report. The context included vaccine hesitancy and ethical concerns from GPs in opposition with MOH. The process involved a diversity of stakeholders with a complex governance and no strict monitoring of the measure. Conclusions: Complex vaccination policy governance associated with a non-evidence-informed policy content and an unfavourable context may have been the reasons for the policy failure.

Increased Risk of Thrombosis Associated with Peripherally Inserted Central Catheters Compared with Conventional Central Venous Catheters in Children with Leukemia.

OBJECTIVE: To study the risk of catheter-associated thrombosis (CAT) between peripherally inserted central catheters (PICCs) and tunneled central venous catheters in children with leukemia. STUDY DESIGN: We analyzed all PICCs and conventional tunneled catheters placed in patients aged <18 years and admitted to our institute for leukemia treatment between February 2008 and April 2014. Cases of symptomatic CAT were confirmed by ultrasound and treated with low-molecular-weight heparin. RESULTS: During the study period, 157 PICCs and 138 conventional tunneled catheters were placed in 192 patients with leukemia. CAT incidence was 1.5% (n = 2) in the conventional tunneled catheter group and 10.2% (n = 16) in the PICC group. The OR for CAT occurrence after PICC vs conventional tunneled catheter placement was 5.6 (95% CI, 1.2-26.5). CONCLUSION: Our results suggest that the use of PICCs in children with leukemia increases the risk of CAT in comparison with the use of conventional tunneled catheters. Further randomized controlled studies are needed to characterize this risk and to better define indications.

Estimation of Extra Length of Stay Attributable to Hospital-Acquired Infections in Adult ICUs Using a Time-Dependent Multistate Model.

OBJECTIVES: The objective of the study was to estimate the length of stay of patients with hospital-acquired infections hospitalized in ICUs using a multistate model. DESIGN: Active prospective surveillance of hospital-acquired infection from January 1, 1995, to December 31, 2012. SETTING: Twelve ICUs at the University of Lyon hospital (France). PATIENTS: Adult patients age greater than or equal to 18 years old and hospitalized greater than or equal to 2 days were included in the surveillance. All hospital-acquired infections (pneumonia, bacteremia, and urinary tract infection) occurring during ICU stay were collected. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The competitive risks of in-hospital death, transfer, or discharge were considered in estimating the change in length of stay due to infection(s), using a multistate model, time of infection onset. Thirty-three thousand four-hundred forty-nine patients were involved, with an overall hospital-acquired infection attack rate of 15.5% (n = 5,176). Mean length of stay was 27.4 (± 18.3) days in patients with hospital-acquired infection and 7.3 (± 7.6) days in patients without hospital-acquired infection. A multistate model-estimated mean found an increase in length of stay by 5.0 days (95% CI, 4.6-5.4 d). The extra length of stay increased with the number of infected site and was higher for patients discharged alive from ICU. No increased length of stay was found for patients presenting late-onset hospital-acquired infection, more than the 25th day after admission. CONCLUSIONS: An increase length of stay of 5 days attributable to hospital-acquired infection in the ICU was estimated using a multistate model in a prospective surveillance study in France. The dose-response relationship between the number of hospitalacquired infection and length of stay and the impact of early-stage hospital-acquired infection may strengthen attention for clinicians to focus interventions on early preventions of hospital-acquired infection in ICU.

Coding acute stroke care and telestroke with the International Classification of Health Interventions (ICHI).

BACKGROUND: and purpose: Acute stroke care is to detect, diagnose, and treat patients in the shortest amount of time. Access to acute stroke care may however be limited in some areas and telemedicine has been thus used to increase its access. Coding acute stroke care as a health intervention had limited attention in the past. METHODS: The International Classification of Health Interventions (ICHI) currently under development was used to identify existing codes relevant for coding acute stroke care interventions, including telestroke. A review of the ICHI was conducted to identify codes relevant for acute stroke care by two independent reviewers. RESULTS: A matching ICHI code was found for each of the steps in the acute stroke care process but no ICHI codes were available to specifically capture telestroke. CONCLUSION: As telemedicine intervention is likely to become more common in the future, it will be imperative that the ICHI is able to code such interventions.

Use of surveillance data to calculate the sample size and the statistical power of randomized clinical trials testing Staphylococcus aureus vaccine efficacy in orthopedic surgery.

BACKGROUND: Patients undergoing primary total hip arthroplasty (THA) would be a worthy population for anti-staphylococcal vaccines. The objective is to assess sample size for significant vaccine efficacy (VE) in a randomized clinical trial (RCT). METHODS: Data from a surveillance network of surgical site infection in France between 2008 and 2011 were used. The outcome was S. aureus SSI (SASSI) within 30 days after surgery. Statistical power was estimated by simulations repeated for theoretical VE ranging from 20% to 100% and for sample sizes from 250 to 8000 individuals per arm. RESULTS: 18,688 patients undergoing THA were included; 66 (0.35%) SASSI occurred. For a 1% SASSI rate, the sample size would be at least 1316 patients per arm to detect significant VE of 80% with 80% power. CONCLUSION: Simulations with real-life data from surveillance of hospital acquired infections allow estimation of power for RCT and sample size to reach the required power.

Heat map for data visualization in infection control epidemiology: An application describing the relationship between hospital-acquired infections, Simplified Acute Physiological Score II, and length of stay in adult intensive care units.

BACKGROUND: Hospital-acquired infections (HAIs) in intensive care units (ICUs) are associated with increased length of stay (LOS). The objective of this study was to graphically describe by heat mapping LOS of patients hospitalized in ICUs related to the occurrence of HAI and severity at admission measured by the Simplified Acute Physiological Score II (SAPSII). METHODS: Adult patients hospitalized in ICUs of Lyon University Hospitals (France) were included in an active standardized surveillance study of HAI from January 1, 1995-December 31, 2012. Surveillance included adult patients aged ≥18 years hospitalized ≥2 days. Patient follow-up ended at ICU discharge or death. LOS was calculated in days from differences between dates of entry and discharge from ICUs. HAIs recorded were pneumonia, bacteremia, and urinary tract infection. The heat map was designed with a spreadsheet software. RESULTS: A total of 34,694 patients were analyzed. Among infected patients, 72.3% had 1 infected site (IS), 23% had 2 ISs, and 4.7% had 3 ISs. Median LOS was 24 days in infected patients (20.4 days among patients with 1 IS, 34.2 days among patients with 2 ISs, and 45.3 days among patients with 3 ISs) and 5 days in noninfected patients (P < .001). Two groups of multi-infected patients with long LOSs were identified with the heat map. CONCLUSIONS: The heat map facilitated easy-to-implement semi-quantitative visualization of increasing LOS through the SAPSIIs and number of ISs.

A systematic review of serious video games used for vaccination.

INTRODUCTION: Vaccination is an effective and proven method of preventing infectious diseases. However, uptake has not been optimal with available vaccines partly due to vaccination hesitancy. Various public health approaches have adressed vaccination hesitancy. Serious video games involving vaccination may represent an innovative public health approach. The aim of this study was to identify, describe, and review existing serious video games on vaccination. METHOD: A systematic review was performed. Various databases were used to find data on vaccination-related serious video games published from January 1st 2000 to May 15th 2015. Data including featured medical and vaccination content, publication characteristics and games classification were collected for each identified serious game. RESULTS: Sixteen serious video games involved in vaccination were identified. All games were developed in high-income countries between 2003 and 2014. The majority of games were available online and were sponsored by educational/health institutions. All games were free of charge to users. Edugame was the most prevalent serious game subcategory. Twelve games were infectious disease-specific and the majority concerned influenza. The main objective of the games was disease control with a collective perspective. Utilization data was available for two games. Two games were formally evaluated. DISCUSSION: The use of serious video games for vaccination is an innovative tool for public health. Evaluation of vaccination related serious video games should be encouraged to demonstrate their efficacy and utility.