An optimization model for reducing thrombectomy center rotations while maintaining medical accessibility.

BACKGROUND/PURPOSE: This study addresses the delicate balance between healthcare personnel burnout and medical accessibility in the context of endovascular thrombectomy (EVT) services in urban areas. We aimed to determine the minimum number of hospitals providing EVT on rotation each day without compromising patient access. METHODS: Employing an optimization model, we developed shift schedules based on patient coverage rates and volumes during the pre-pandemic (2016-2018) and pandemic (2019-2021) periods. Starting with a minimum of two hospitals on duty per day, we gradually increased to a maximum of eight. Patient coverage rates, defined as the proportion of patients meeting bypass criteria and transported to rotating hospitals capable of EVT, were the primary outcomes. Sensitivity analyses explored the impact of varying patient transport intervals and accumulating patients over multiple years. RESULTS: Results from 7024 patient records revealed patient coverage rates of 92.5% (standard deviation [SD] 2.8%) during the pre-pandemic and 91.4% (SD 2.8%) during the pandemic, with at least two rotating hospitals daily. No significant differences were observed between schedules based on the highest patient volume and coverage rate months. A patient coverage rate of 98.99% was achieved with four rotating hospitals per day during the pre-pandemic period, with limited improvement beyond this threshold. Changing patient transport intervals and accumulating patients over six years (p = 0.83) had no significant impact on coverage rates. CONCLUSION: Our optimization model supports reducing the number of daily rotating hospitals by half while preserving a balance between patient accessibility and alleviating strain on medical teams.

Costs and Cardiovascular Benefits of a Fourth-Generation Synchronous Telehealth Program on Mortality and Cardiovascular Outcomes for Patients With Atrial Fibrillation: Retrospective Cohort Study.

BACKGROUND: The prevalence of atrial fibrillation (AF) continues to increase in modern aging society. Patients with AF are at high risk for multiple adverse cardiovascular events, including heart failure, stroke, and mortality. Improved medical care is needed for patients with AF to enhance their quality of life and limit their medical resource utilization. With advances in the internet and technology, telehealth programs are now widely used in medical care. A fourth-generation telehealth program offers synchronous and continuous medical attention in response to physiological parameters measured at home. Although we have previously shown the benefits of this telehealth program for some patients with a high risk of cardiovascular disease, its benefits for patients with AF remains uncertain. OBJECTIVE: This study aims to investigate the benefits of participating in a fourth-generation telehealth program for patients with AF in relation to cardiovascular outcomes. METHODS: This was a retrospective cohort study. We retrospectively searched the medical records database of a tertiary medical center in Northern Taiwan between January 2007 and December 2017. We screened 5062 patients with cardiovascular disease and enrolled 537 patients with AF, of which 279 participated in the telehealth program and 258 did not. Bias was reduced using the inverse probability of treatment weighting adjustment based on the propensity score. Outcomes were collected and analyzed, including all-cause readmission, admission for heart failure, acute coronary syndrome, ischemic stroke, systemic embolism, bleeding events, all-cause mortality, and cardiovascular death within the follow-up period. Total medical expenses and medical costs in different departments were also compared. Subgroup analyses were conducted on ischemic stroke stratified by several subgroup variables. RESULTS: The mean follow-up period was 3.0 (SD 1.7) years for the telehealth group and 3.4 (SD 1.9) years for the control group. After inverse probability of treatment weighting adjustment, the patients in the telehealth program had significantly fewer ischemic strokes (2.0 vs 4.5 events per 100 person-years; subdistribution hazard ratio [SHR] 0.45, 95% CI 0.22-0.92) and cardiovascular deaths (2.5 vs 5.9 events per 100 person-years; SHR 0.43, 95% CI 0.18-0.99) at the follow-up. The telehealth program particularly benefited patients comorbid with vascular disease (SHR 0.11, 95% CI 0.02-0.53 vs SHR 1.16, 95% CI 0.44-3.09; P=.01 for interaction). The total medical expenses during follow-up were similar in the telehealth and control groups. CONCLUSIONS: This study demonstrated the benefits of participating in the fourth-generation telehealth program for patients with AF by significantly reducing their ischemic stroke risk while spending the same amount on medical expenses.

The Impact of Synchronous Telehealth Services With a Digital Platform on Day-by-Day Home Blood Pressure Variability in Patients with Cardiovascular Diseases: Retrospective Cohort Study.

BACKGROUND: Hypertension is associated with a large global disease burden with variable control rates across different regions and races. Telehealth has recently emerged as a health care strategy for managing chronic diseases, but there are few reports regarding the effects of synchronous telehealth services on home blood pressure (BP) control and variability. OBJECTIVE: The objective of this study is to investigate the effect of synchronous telehealth services with a digital platform on home BP. METHODS: This retrospective study was conducted by the Taiwan ELEctroHEALTH study group at the Telehealth Center of the National Taiwan University Hospital. We analyzed home BP data taken from 2888 patients with cardiovascular disease (CVD) enrolled in our telehealth program between 2009 to 2017. Of the 2888 patients with CVD, 348 (12.05%) patients who received home BP surveillance for ≥56 days were selected for BP analysis. Patients were stratified into three groups: (1) poorly controlled hypertension, (2) well-controlled hypertension, and (3) nonhypertension. The mean, SD, coefficient of variation (CV), and average real variability were calculated. RESULTS: Telehealth interventions significantly and steadily reduced systolic blood pressure (SBP) in the poorly controlled hypertension group from 144.8.2±9.2 to 133.7±10.2 mmHg after 2 months (P<.001). BP variability reduced in all patients: SBP-SD decreased from 7.8±3.4 to 7.3±3.4 after 2 months (P=.004), and SBP-CV decreased from 6.3±2.5 to 5.9±2.6 after 2 months (P=.004). Event-free survival (admission) analysis stratified by SBP-SD showed longer time to first hospitalization for Q1 patients compared with Q4 patients (P=.02, odds ratio 2.15, 95% CI 1.18-3.89). CONCLUSIONS: Synchronous telehealth intervention may improve home BP control and decrease day-by-day home BP variability in patients with CVD.

The Costs and Cardiovascular Benefits in Patients With Peripheral Artery Disease From a Fourth-Generation Synchronous Telehealth Program: Retrospective Cohort Study.

BACKGROUND: Patients with peripheral artery disease (PAD) are at high risk for major cardiovascular events, including myocardial infarction, stroke, and hospitalization for heart failure. We have previously shown the clinical efficacy of a fourth-generation synchronous telehealth program for some patients, but the costs and cardiovascular benefits of the program for PAD patients remain unknown. OBJECTIVE: The telehealth program is now widely used by higher-risk cardiovascular patients to prevent further cardiovascular events. This study investigated whether patients with PAD would also have better cardiovascular outcomes after participating in the fourth-generation synchronous telehealth program. METHODS: This was a retrospective cohort study. We screened 5062 patients with cardiovascular diseases who were treated at National Taiwan University Hospital and then enrolled 391 patients with a diagnosis of PAD. Of these patients, 162 took part in the telehealth program, while 229 did not and thus served as control patients. Inverse probability of treatment weighting (IPTW) based on the propensity score was used to mitigate possible selection bias. Follow-up outcomes included heart failure hospitalization, acute coronary syndrome, stroke, and all-cause readmission during the 1-year follow-up period and through the last follow-up. RESULTS: The mean follow-up duration was 3.1 (SD 1.8) years for the patients who participated in the telehealth program and 3.2 (SD 1.8) for the control group. The telehealth program patients exhibited lower risk of ischemic stroke than did the control group in the first year after IPTW (0.9% vs 3.5%; hazard ratio [HR] 0.24; 95% CI 0.07-0.80). The 1-year composite endpoint of vascular accident, including acute coronary syndrome and stroke, was also significantly lower in the telehealth program group after IPTW (2.4% vs 5.2%; HR 0.46; 95% CI 0.21-0.997). At the end of the follow-up, the telehealth program group continued to exhibit a significantly lower rate of ischemic stroke than did the control group after IPTW (0.9% vs 3.5%; HR 0.52, 95% CI 0.28-0.93). Furthermore, the medical costs of the telehealth program patients were not higher than those of the control group, whether in terms of outpatient, emergency department, hospitalization, or total costs. CONCLUSIONS: The PAD patients who participated in the fourth-generation synchronous telehealth program exhibited lower risk of ischemic stroke events over both mid- and long-term follow-up periods. However, larger-scale and prospective randomized clinical trials are needed to confirm our findings.

Use of the CHA2DS2-VASc Score for Risk Stratification of Hospital Admissions Among Patients With Cardiovascular Diseases Receiving a Fourth-Generation Synchronous Telehealth Program: Retrospective Cohort Study.

BACKGROUND: Telehealth programs are generally diverse in approaching patients, from traditional telephone calling and texting message and to the latest fourth-generation synchronous program. The predefined outcomes are also different, including hypertension control, lipid lowering, cardiovascular outcomes, and mortality. In previous studies, the telehealth program showed both positive and negative results, providing mixed and confusing clinical outcomes. A comprehensive and integrated approach is needed to determine which patients benefit from the program in order to improve clinical outcomes. OBJECTIVE: The CHA2DS2-VASc (congestive heart failure, hypertension, age >75 years [doubled], type 2 diabetes mellitus, previous stroke, transient ischemic attack or thromboembolism [doubled], vascular disease, age of 65-75 years, and sex) score has been widely used for the prediction of stroke in patients with atrial fibrillation. This study investigated the CHA2DS2-VASc score to stratify patients with cardiovascular diseases receiving a fourth-generation synchronous telehealth program. METHODS: This was a retrospective cohort study. We recruited patients with cardiovascular disease who received the fourth-generation synchronous telehealth program at the National Taiwan University Hospital between October 2012 and June 2015. We enrolled 431 patients who had joined a telehealth program and compared them to 1549 control patients. Risk of cardiovascular hospitalization was estimated with Kaplan-Meier curves. The CHA2DS2-VASc score was used as the composite parameter to stratify the severity of patients' conditions. The association between baseline characteristics and clinical outcomes was assessed via the Cox proportional hazard model. RESULTS: The mean follow-up duration was 886.1 (SD 531.0) days in patients receiving the fourth-generation synchronous telehealth program and 707.1 (SD 431.4) days in the control group (P<.001). The telehealth group had more comorbidities at baseline than the control group. Higher CHA2DS2-VASc scores (≥4) were associated with a lower estimated rate of remaining free from cardiovascular hospitalization (46.5% vs 54.8%, log-rank P=.003). Patients with CHA2DS2-VASc scores ≥4 receiving the telehealth program were less likely to be admitted for cardiovascular disease than patients not receiving the program. (61.5% vs 41.8%, log-rank P=.01). The telehealth program remained a significant prognostic factor after multivariable Cox analysis in patients with CHA2DS2-VASc scores ≥4 (hazard ratio=0.36 [CI 0.22-0.62], P<.001). CONCLUSIONS: A higher CHA2DS2-VASc score was associated with a higher risk of cardiovascular admissions. Patients accepting the fourth-generation telehealth program with CHA2DS2-VASc scores ≥4 benefit most by remaining free from cardiovascular hospitalization.

Mortality Benefit of a Fourth-Generation Synchronous Telehealth Program for the Management of Chronic Cardiovascular Disease: A Longitudinal Study.

BACKGROUND: We have shown that a fourth-generation telehealth program that analyzes and responds synchronously to data transferred from patients is associated with fewer hospitalizations and lower medical costs. Whether a fourth-generation telehealth program can reduce all-cause mortality has not yet been reported for patients with chronic cardiovascular disease. OBJECTIVE: We conducted a clinical epidemiology study retrospectively to determine whether a fourth-generation telehealth program can reduce all-cause mortality for patients with chronic cardiovascular disease. METHODS: We enrolled 576 patients who had joined a telehealth program and compared them with 1178 control patients. A Cox proportional hazards model was fitted to analyze the impact of risk predictors on all-cause mortality. The model adjusted for age, sex, and chronic comorbidities. RESULTS: There were 53 (9.3%) deaths in the telehealth group and 136 (11.54%) deaths in the control group. We found that the telehealth program violated the proportional hazards assumption by the Schoenfeld residual test. Thus, we fitted a Cox regression model with time-varying covariates. The results showed an estimated hazard ratio (HR) of 0.866 (95% CI 0.837-0.896, P<.001; number needed to treat at 1 year=55.6, 95% CI 43.2-75.7 based on HR of telehealth program) for the telehealth program on all-cause mortality after adjusting for age, sex, and comorbidities. The time-varying interaction term in this analysis showed that the beneficial effect of telehealth would increase over time. CONCLUSIONS: The results suggest that our fourth-generation telehealth program is associated with less all-cause mortality compared with usual care after adjusting for chronic comorbidities.

Assessment of the cost-effectiveness and clinical outcomes of a fourth-generation synchronous telehealth program for the management of chronic cardiovascular disease.

BACKGROUND: Telehealth programs are a growing field in the care of patients. The evolution of information technology has resulted in telehealth becoming a fourth-generation synchronous program. However, long-term outcomes and cost-effectiveness analysis of fourth-generation telehealth programs have not been reported in patients with chronic cardiovascular diseases. OBJECTIVE: We conducted this study to assess the clinical outcomes and cost-effectiveness of a fourth-generation synchronous telehealth program for patients with chronic cardiovascular diseases. METHODS: We retrospectively analyzed 575 patients who had joined a telehealth program and compared them with 1178 patients matched for sex, age, and Charlson comorbidity index. The program included: (1) instant transmission of biometric data, (2) daily telephone interview, and (3) continuous decision-making support. Data on hospitalization, emergency department (ED) visits, and medical costs were collected from the hospital's database and were adjusted to the follow-up months. RESULTS: The mean age was 64.5 years (SD 16.0). The mean number of monthly ED visits (mean 0.06 SD 0.13 vs mean 0.09 SD 0.23, P<.001), hospitalizations (mean 0.05 SD 0.12 vs mean 0.11 SD 0.21, P<.001), length of hospitalization (mean 0.77 days SD 2.78 vs mean 1.4 SD 3.6, P<.001), and intensive care unit admissions (mean 0.01 SD 0.07 vs mean 0.036 SD 0.14, P<.001) were lower in the telehealth group. The monthly mean costs of ED visits (mean US$20.90 SD 66.60 vs mean US$37.30 SD 126.20, P<.001), hospitalizations (mean US$386.30 SD 1424.30 vs mean US$878.20 SD 2697.20, P<.001), and all medical costs (mean US$587.60 SD 1497.80 vs mean US$1163.60 SD 3036.60, P<.001) were lower in the telehealth group. The intervention costs per patient were US$224.80 per month. Multivariate analyses revealed that age, telehealth care, and Charlson index were the independent factors for ED visits, hospitalizations, and length of hospitalization. A bootstrap method revealed the dominant cost-effectiveness of telehealth care over usual care. CONCLUSIONS: Better cost-effectiveness and clinical outcomes were noted with the use of a fourth-generation synchronous telehealth program in patients with chronic cardiovascular diseases. The intervention costs of this new generation of telehealth program do not increase the total costs for patient care.

Theoretical system dynamics modeling for Taiwan pediatric workforce in an era of national health insurance and low birth rates.

BACKGROUND: In an era of declining birth rates and a single-payer health care system, the pediatric workforce might overreact to its demands. System dynamics (SD) were therefore applied to establish models to predict the future need and demand for the pediatric workforce. MATERIALS AND METHODS: Data of population and workforce were extracted from national databases and models developed using Vensim software. RESULTS: In the past decade, the child-to-pediatrician ratio correlated with infant mortality in Taiwan (p < 0.001, r(2) = 0.88, child-to-pediatrician ratio = 146 + 354 × infant mortality/1000 live births). Currently, the child-to-pediatrician ratio is 1742:1. Using the Millennium Development Goals (2.437/1000 live births) for infant mortality, the child-to-pediatrician ratio was estimated as 1009:1. The pediatric population model incorporated the birth and mortality rates in each age category, accurately predicted population changes between 1974 and 2010, and projected a decreasing trend until 2017. The pediatric workforce model, which considered rates of enrollment, completion, certification, and retention, predicted a decrease in the supply of pediatricians in the mid-2010s that could be delayed by policy incentives. When targeting the base scenario, the model indicated that discrepancies between demands and supply of pediatricians would occur in the late 2010s toward 2020. When targeting the Millennium Development Goals scenario, however, the discrepancies would be consistent. CONCLUSION: Effective SD models were developed for the population and health care workforce. The strengths of the SD models are derived from simulation, which is subject to influence from new policies. Policies can, therefore, be examined and intervened in a timely manner.