Implementation of Video Blood Pressure Visits in the Veterans Health Administration.

Introduction: Almost half of veterans (44.6%) seen in the U.S. Department of Veterans Affairs outpatient setting are diagnosed with hypertension (HTN). Because of the widespread nature of HTN, use of virtual visits has the potential to improve blood pressure (BP) management. This evaluation assessed the effectiveness of video blood pressure visits (VBPVs) in the management of HTN in veterans enrolled in Veterans Health Administration primary care. Methods: The program was implemented within the existing veteran-centered medical home. VBPVs are scheduled where the nurse observes veterans taking their BP and provides teaching or counseling. A national training curriculum was delivered to local nurse champions through Microsoft Teams. We analyzed improvement in BP over a 2-year period. We also captured actions taken by nurses during the VBPV by searching the electronic notes. Ratings of training and comments were summarized using feedback forms completed after training. Results: In total, 81,476 veterans participated in VBPVs over 2 years. Of those, 44,682 veterans had an existing ICD-10 code related to HTN. Of the 18,078 veterans who had a pre- and post-VBPV BP, the average change to systolic measurement was -10.6 mm Hg (range -82 to 78). Average change to diastolic measurement was -4.61 mm Hg (range -59 to 55). Most interventions addressed medication management (77%). Nurses' evaluations of the program were positive. Conclusions: Video visits provide reliable and convenient veteran-centered care. Such visits enable care when unanticipated interruptions occur such as the coronavirus disease 2019 pandemic. In addition to medication management, nurse-led interventions such as counseling on lifestyle changes can be effective in HTN management.

Echocardiography Learning by Pediatricians While Screening Congenital Heart Disease with the Aid of Telemedicine.

Background: Congenital heart disease (CHD) affects 1% of all newborns and is a major public health problem. Most children with CHD benefit from early diagnosis to optimize management. However, in many places there are no specialized professionals to do so. Introduction: A screening method for CHD was developed between two states in Northeast Brazil. It was based upon the performance of an echocardiogram by local pediatricians with support of pediatric cardiologists through telemedicine. Objective: To determine if the continuous performance of examinations together with online supervision increased the level of understanding of the pediatricians about the echocardiograms. Methods: Pediatricians received online support to perform echocardiograms for 7 years (2012-2018). Although the project aimed to teach them to acquire images and send to the cardiologists for analysis and interpretation, they were encouraged to describe their own diagnostic impressions. The level of agreement between pediatricians and cardiologists was calculated. Results: A large number (n = 3,951) echocardiograms was analyzed. From them, 2,818 were classified as abnormal, inconclusive, or normal by both the pediatricians and the cardiologists. The 7-year analysis demonstrated an overall agreement of 63.7%. As for the final diagnosis, it was possible to compare 1,457 echocardiograms. The combined analysis of the 7 years demonstrated agreement in 62.2%. Discussion: The screening of CHD under online support led to more in-depth learning of echocardiography by the pediatricians. This approach potentialized the accuracy of the screening through the years. Conclusion: By enrolling in a telemedicine-based screening program, the pediatricians' degree of understanding of echocardiography increased considerably.

Functional Outcomes of Intravenous Thrombolysis in Octogenarians and Nonagenarians Through Telestroke: Single-Center Experience.

Background: Patients aged ≥80 years are often underrepresented in stroke trials. Observational studies have shown that older patients have worse outcomes compared with younger patients, but outcomes in patients aged ≥80 years treated with intravenous (IV)-alteplase specifically through telestroke (TS) have not been studied. Aim: To compare clinical and safety outcomes in stroke patients aged ≥80 and 60-79 years treated with IV-alteplase via TS. Methods: The Medical University of South Carolina TS database was analyzed to identify IV-alteplase-treated patients aged 60-79 and ≥80 years between January 2015 and March 2018. Baseline demographics and TS-specific variables were compared. Clinical outcomes were assessed using the 90-day modified Rankin Scale (mRS). Safety outcomes were evaluated by comparing symptomatic intracranial hemorrhage (sICH). Multivariate logistic regression analysis was performed to determine odds ratio (OR) for good outcome (mRS 0-2) in the older age group at 90 days. Results: IV-alteplase was used in 151 patients in ≥80 years age group and 273 patients in 60-79 years age group. The older age group had more women and a higher National Institutes of Health Stroke Scale. The mean "ED-door-to-TS-consultant-login" time was shorter (21.6 min vs. 25.6 min; p = 0.048), but "TS-consultant-login-to-alteplase" time was longer (22.1 min vs. 19.3 min; p = 0.01) in the older age group. No difference was noted in eventual "door-to-needle" time. The older age group had fewer good outcomes (39.1% vs. 74%; p = 0.001) and more deaths (38% vs. 14%; p = 0.001) at 90 days. The sICH rates were similar in the two groups. The OR for good outcome in ≥80 years age group was 0.20 (95% CI: 0.12-0.34) after controlling for baseline variables. Conclusions: Stroke patients aged ≥80 years treated via TS have similar post-thrombolysis hemorrhage rates but worse clinical outcomes compared with patients aged 60-79 years.

Development and Assessment of a Mobile Nutritional Counseling Tool for Primary Care Physicians.

Background:Hypertension remains widely undetected, undertreated, and poorly controlled. Appropriate dietary changes can prevent and treat hypertension effectively. Primary care physicians (PCPs) have the opportunity to counsel patients about their diets and are able to facilitate long-term adherence to changes. However, they encounter several barriers to delivery of evidence-based counseling in daily medical practice. m-Health can make important contributions.Objective:To describe the development and assessment of a Brazilian mobile app for nutritional management of hypertension supported by evidence-based.Materials and Methods:App development used a user-centered approach that seeks to solve problems in a collective and collaborative way. The app was developed in Apache Cordova® (Adobe Systems, San Jose, CA) for iOS and Android mobile phone platforms. Beta testing was performed with a sample of Brazilian PCPs (n = 62), who were asked to use the app in routine practice and evaluate it.Results:The process involved researchers, government, PCPs, nutritionists, and designers. Dieta Dash® (Universidade Federal do Rio Grande do Sul-UFRGS, Porto Alegre, Brazil) app was divided into following sections: meal evaluation, Healthy meals, Healthy choices, and a database of Healthy recipes. The mean perceived usefulness and ease-of-use scores were 23.3 and 32.3 out of 42, respectively.Conclusions:It is a great source of up-to-date and summary guidelines, usable, acceptable, and positively impact clinical care. PCPs have identified improvements that could make the user experience better. The Dieta Dash app can be incorporated into Brazilian primary care practice.

Emergency Department Telemedicine Consults are Associated with Faster Time-to-Electrocardiogram and Time-to-Fibrinolysis for Myocardial Infarction Patients.

Introduction: Acute myocardial infarction (AMI) is a time-sensitive condition. Meeting guideline-recommended time metrics for these patients can be challenging in rural emergency departments (EDs). Telemedicine has been shown to improve the quality and timeliness of emergency care in rural areas. The objective of this study was to evaluate the impact of telemedicine on the timeliness of emergency AMI care for patients presenting to rural EDs with chest pain. Methods: A prospective cohort study, conducted in six telemedicine networks, identified ED patients presenting with chest pain from November 2015 through December 2017. Primary exposure was telemedicine consultation during the ED visit. The primary outcome was time-to-electrocardiogram (ECG). For eligible AMI patients, secondary outcomes included: (1) fibrinolysis administered and (2) time-to-fibrinolysis. Analyses for multivariable models were conducted by using logistic regression, clustered at the hospital level. Results: Overall, 1,220 patients presenting with chest pain were included in the study cohort (27.1% received telemedicine). Time-to-ECG was, on average, 0.39 times (95% confidence interval [CI] -0.26 to -0.52) faster for telemedicine cases. Among eligible patients, telemedicine was associated with higher odds of fibrinolysis administration (adjusted odds ratio 7.17, 95% CI 2.48-20.49). In a sensitivity analysis excluding patients with cardiac arrest, time-to-fibrinolysis administration did not differ when telemedicine was used. Discussion: In telemedicine networks, telemedicine consultation during the ED visit was associated with improved timeliness of ECG evaluation and increased use of fibrinolytic reperfusion therapy for rural AMI patients. Future work should focus on the impact of telemedicine consultation on patient-centered outcomes.

Application of Telemedicine for the Control of Patients with Acute and Chronic Heart Diseases.

Introduction: Telemedicine (TM) has transformed the field of emergency cardiology, particularly the treatment of acute myocardial infarction (AMI). The ability to record an electrocardiogram (EKG) in the early prehospital phase, thus avoiding any delay in diagnosing myocardial infarction with direct transfer to the cath-lab for primary angioplasty, has proven to significantly reduce treatment times and mortality. Materials and Methods: We analyzed the available evidence and organizational models based on a support by TM in cardiology, including the applications of TM in cardiovascular disease based on a review of the literature. Results: The most important areas of application of TM in the field of cardiology are as follows: (1) Early prehospital diagnosis of AMI with EKG transmission; (2) Patient Remote control through wearable and devices; (3) Monitoring of patients with chronic heart failure; (4) Monitoring of patient's arrhythmias; and (5) Transmission of echo images to a III level center for a "second opinion". Conclusions: TM services should, therefore, be considered as a true diagnostic/therapeutic aspect of cardiovascular emergencies. It is necessary to educate medical staff and to provide a tempting environment for software engineers. Investing in infrastructure and equipment is imperative, as well as a positive climate for its implementation.

A Randomized Controlled Trial Comparing Telehealth Self-Management to Standard Outpatient Management in Underserved Black and Hispanic Patients Living with Heart Failure.

Background:Although the American Heart Association promotes telehealth models to improve care access, there is limited literature on its use in underserved populations. This study is the first to compare utilization and quality of life (QoL) for underserved black and Hispanic heart failure (HF) patients assigned to telehealth self-monitoring (TSM) or comprehensive outpatient management (COM) over 90 days.Methods:This randomized controlled trial enrolled 104 patients. Outcomes included emergency department (ED) visits, hospitalizations, QoL, depression, and anxiety. Binary outcomes for utilization were analyzed using chi-square or Fisher's exact test. Poisson or negative binomial regression, repeated-measures analysis of variance, or generalized estimating equations were also used as appropriate.Results:Of 104 patients, 31% were Hispanic, 69% black, 41% women, and 72% reported incomes of <$10,000/year. Groups did not differ regarding binary ED visits (relative risk [RR] = 1.37, confidence interval [CI] = 0.83-2.27), hospitalization (RR = 0.92, CI = 0.57-1.48), or length of stay in days (TSM = 0.54 vs. COM = 0.91). Number of all-cause hospitalizations was significantly lower for COM (TSM = 0.78 vs. COM = 0.55; p = 0.03). COM patients reported greater anxiety reduction from baseline to 90 days (TSM = 50-28%; COM = 57-13%; p = 0.05).Conclusions:These findings suggest that TSM is not effective in reducing utilization or improving QoL for underserved patients with HF. Future studies are needed to determine whether TSM can be effective for populations facing health care access issues.

Successful Fetal Tele-Echo at a Small Regional Hospital.

BACKGROUND: Prenatal diagnosis of complex congenital heart disease (CHD) has been shown to improve newborn outcomes. The rate of prenatal diagnosis and access to fetal echocardiography vary widely across the United States. INTRODUCTION: A clinical fetal tele-echo service was established at King's Daughters Medical Center (KDMC) in Ashland, KY, a region in eastern Kentucky that is 3 h from the nearest congenital heart surgeon. The aim of this study was to determine if fetal tele-echo utilizing local sonographers at a small regional hospital can accurately and efficiently identify fetuses with complex CHD. METHODS: Medical records were reviewed for all mother-infant pairs who had fetal tele-echoes performed at KDMC and interpreted by University of Louisville pediatric cardiology between March 2011 and December 2013. Findings on fetal tele-echo were compared to newborn echo and clinical course, and divided into four groups: (1) Correct-no difference between fetal tele-echo and newborn echo, (2) Likely Correct-normal fetal tele-echo and benign newborn course, (3) Major Difference-one that affected newborn clinical course, and (4) Minor Difference-did not affect clinical course. RESULTS: Seventy-five mother-infant pairs were analyzed. Fetal tele-echoes were Correct in 21%, Likely Correct in 56%, showed Major Differences in 0%, and showed Minor Differences in 23%. For identifying complex CHD, fetal tele-echo had a sensitivity and specificity of 100%. The average number of fetal echocardiograms per mother-infant pair was 1.1. DISCUSSION: Fetal tele-echocardiography performed by local sonographers at a small regional hospital can accurately and efficiently identify fetuses with complex CHD.

Mobile Diagnostic Units for Rural Patients in Colombia.

BACKGROUND: The literature on the use of mobile diagnostic units for the adult population is limited. This is a report for the first time in Colombia (Latin America) on the use of mobile diagnostic units for patients in rural areas and resolution of complex cases through telemedicine. INTRODUCTION: Telemedicine is an alternative because it takes advantage of advances in telecommunications and technology for the provision of health services to patients in rural areas of a country. MATERIALS AND METHODS: A pilot program for mobile patient diagnosis was developed in three rural areas of central Colombia. The mobile unit was named Mobile dIagnostiC Unit (MICU). The unit includes a medical stretcher, dresser, washbasin, computer, videoconference equipment, satellite connectivity, and digital medical equipment: electrocardiogram, stethoscope, oximeter, and thermometer. RESULTS: The number of patients attended during the 3 days of activity was 108, ∼36 each day. None of the patients (100%) was familiar with digital diagnostic tools and telemedicine. The entire population who attended (100%) was satisfied with the care, health education, and diagnosis received. DISCUSSION: Our case report shows that the use of MICUs with the support of telemedicine offers benefit to the rural population in the geographic zone chosen in Colombia. CONCLUSIONS: With greater coverage and access for patients to health services via mobile telemedicine units, it is possible to increase the quality of care.

Development and Validation of an Interactive Internet Platform for Older People: The Healthy Ageing Through Internet Counselling in the Elderly Study.

BACKGROUND: A myriad of Web-based applications on self-management have been developed, but few focus on older people. In the face of global aging, older people form an important target population for cardiovascular prevention. This article describes the full development of an interactive Internet platform for older people, which was designed for the Healthy Ageing Through Internet Counselling in the Elderly (HATICE) study. We provide recommendations to design senior-friendly Web-based applications for a new approach to multicomponent cardiovascular prevention. METHODS: The development of the platform followed five phases: (1) conceptual framework; (2) platform concept and functional design; (3) platform building (software and content); (4) testing and pilot study; and (5) final product. RESULTS: We performed a meta-analysis, reviewed guidelines for cardiovascular diseases, and consulted end users, experts, and software developers to create the platform concept and content. The software was built in iterative cycles. In the pilot study, 41 people aged ≥65 years used the platform for 8 weeks. Participants used the interactive features of the platform and appreciated the coach support. During all phases adjustments were made to incorporate all improvements from the previous phases. The final platform is a personal, secured, and interactive platform supported by a coach. DISCUSSION: When carefully designed, an interactive Internet platform is acceptable and feasible for use by older people with basic computer skills. To improve acceptability by older people, we recommend involving the end users in the process of development, to personalize the platform and to combine the application with human support. The interactive HATICE platform will be tested for efficacy in a multinational randomized controlled trial (ISRCTN48151589).

Using Mobile-Health to Connect Women with Cardiovascular Disease and Improve Self-Management.

Background/Introduction: Self-management approaches are regarded as appropriate methods to support patients with cardiovascular disease (CVD) and to prevent secondary complications and hospitalizations. Key to successful self-management is the ability of individuals to enlist peer supports to help sustain motivation and efforts to manage their condition. The purpose of this study was to investigate the proof of concept of a peer-support mobile-health (m-health) program, called Healing Circles, and explore the program's effect on self-management, social support, and health-related quality of life in women with CVD. MATERIALS AND METHODS: Healing Circles is a consumer m-health solution developed to facilitate peer support and self-management by connecting people with CVD in groups of five to nine people. Women with CVD (obstructive coronary artery disease) were included in this single group, pre/post study if they owned an iPhone/iPad with at least iOS 7.0. Participants (n = 21) used the Healing Circles program for a 10-week period. Self-management, social support, and health-related quality-of-life outcomes were assessed before and after the use of the program. User experiences and satisfaction were obtained during an exit interview. RESULTS: After 10 weeks of using the Healing Circles program, statistically significant improvements were observed in the participants' health behaviors (p = 0.04), self-monitoring (p = 0.04), social support (p = 0.01), and social integration (p = 0.002). As well, many women had a level of high satisfaction with the concept of using m-health for the delivery of peer support. CONCLUSION: The delivery of peer and self-management support using m-health technologies is well received and may improve self-management and social support. More research is needed to test hypotheses of the effect of the Healing Circles program on clinical outcomes.

Proposing Telecardiology Services on Cloud for Different Medical Institutions: A Model of Reference.

INTRODUCTION: For a cloud-based telecardiology solution to be established in any scenario, it is necessary to ensure optimum levels of security, as patient's data will not be in the same place from where access is gained. The main objective of this article is to present a secure, cloud-based solution for a telecardiology service in different scenarios: a hospital, a health center in a city, and a group of health centers in a rural area. METHODS: iCanCloud software is used to simulate the scenarios. The first scenario will be a city hospital with over 220,000 patients at its emergency services, and ∼1 million outpatient consultations. For the health center in a city, it serves ∼107,000 medical consultations and 16,700 pediatric consultations/year. In the last scenario, a group of health centers in a rural area serve an average 437.08 consultations/month and around 15.6 a day. RESULTS: Each one of the solutions proposed shares common features including the following: secure authentication through smart cards, the use of StorageGRID technology, and load balancers. For all cases, the cloud is private and the estimated price of the solution would cost around 450 €/month. CONCLUSIONS: Thanks to the research conducted in this work, it has been possible to provide an adapted solution in the form of a telecardiology service for a hospital, city health center, and rural health centers that offer security, privacy, and robustness, and is also optimum for a large number of cloud requests.

Clinical Impact of Telemedicine Network System at Rural Hospitals Without On-Site Cardiac Surgery Backup.

BACKGROUND: In Japan, catheterization laboratories are available in each medical service area. However, cardiovascular centers capable of surgical procedures are concentrated in urban areas. Critically ill patients with complex coronary lesions must be transferred to receive advanced medical care. Interhospital conferencing is necessary for an optimal patient transfer. We investigated the benefit and utility of a Digital Imaging and Communications in Medicine (DICOM) telemedicine network at a rural hospital without on-site cardiac surgery backup in Japan. MATERIALS AND METHODS AND RESULTS: The Kumamoto telemedicine network consists of 2 high-volume centers and 12 rural low-volume hospitals without on-site cardiac surgery. Between January 2010 and December 2014, 293 teleconferences were conducted. At the Aso Medical Center, a low-volume hospital, teleconferences were carried out in 48 cases (30 coronary artery disease, 6 peripheral artery disease, 3 aortic aneurysm, 3 deep vein thrombosis, 2 inflammatory aortitis, 1 annuloaortic ectasia, 1 cardiac tamponade, 1 myocarditis, and 1 heart failure). After the conferences were initiated, 10 cases (20.8%) were transferred to the high-volume center. We investigated the prevalence of patient transfer before and after network system deployment. Telemedicine-based collaborative care significantly decreased the frequency of patient transfers from the Aso area. CONCLUSIONS: The Kumamoto telemedicine network enabled open communication between distant hospitals. This collaboration has the potential to improve cardiac care in rural areas.

The Importance of Walking for Control of Blood Pressure: Proof Using a Telemedicine System.

BACKGROUND: Regular physical activity (PA), including daily walking, reduces the risk of many chronic diseases, especially hypertension. Pedometer is a potential motivational aid for increasing PA. In the present study, we used a telemedicine system and analyzed the relationship between daily walking, calculated by pedometers, and blood pressure (BP). METHODS: BP was measured at home twice a day (morning and evening) using an oscillometric automatic device. Body weight (BW) and percent body fat (%BF) were measured after BP measurement. Daily walking steps (DWS) were calculated by a pedometer. These daily parameters were transmitted through the Internet to a central server computer and sent to the Medical Health Center. RESULTS: Sixty-nine (N = 69) hypertensive patients were included in this study. The mean follow-up period was 378 days. Electronic data from a pedometer (DWS) were associated with reduced BW, body mass index, and %BF. Hypertensive patients were divided into two groups based on the DWS. In the high DWS group, morning systolic BP and diastolic BP and evening systolic BP were reduced after induction of the telemedicine system. CONCLUSION: A telemedicine system confirmed the usefulness of walking to control BP in hypertensive patients.

Health Economic Impact of a Pulmonary Artery Pressure Sensor for Heart Failure Telemonitoring: A Dynamic Simulation.

AIMS: Recently, a permanently implantable wireless system, designed to monitor and manage pulmonary artery (PA) pressures remotely, demonstrated significant reductions in heart failure (HF) hospitalizations in high-risk symptomatic patients, regardless of ejection fraction. The objectives of this study were to simulate the estimated clinical and economic impact in Germany of generalized use of this PA pressure monitoring system considering reductions of HF hospitalizations and the improvement in Quality of Life. MATERIALS AND METHODS: Based on the Prospective Health Technology Assessment approach, we simulated the potential of the widespread application of PA pressure monitoring on the German healthcare system for the period 2009-2021. RESULTS: This healthcare economic simulation formulated input assumptions based on results from the CHAMPION Trial, a multicenter, prospective, randomized controlled U.S. trial that demonstrated a 37% reduction of hospitalizations in persistently symptomatic previous HF patients. Based on these results, an estimated 114,800 hospitalizations would expected to be avoided. This effect would potentially save an estimated €522 million, an equivalent of $575 million, during the entire simulation period. CONCLUSION: This healthcare economic modeling of the PA pressure monitoring system's impact demonstrates substantial clinical and economic benefits in the German healthcare system.

A Flexible and Integrated System for the Remote Acquisition of Neuropsychological Data in Stroke Research.

BACKGROUND: Neuropsychological testing is a central aspect of stroke research because it provides critical information about the cognitive-behavioral status of stroke survivors, as well as the diagnosis and treatment of stroke-related disorders. Standard neuropsychological methods rely upon face-to-face interactions between a patient and researcher, which creates geographic and logistical barriers that impede research progress and treatment advances. INTRODUCTION: To overcome these barriers, we created a flexible and integrated system for the remote acquisition of neuropsychological data (RAND). The system we developed has a secure architecture that permits collaborative videoconferencing. The system supports shared audiovisual feeds that can provide continuous virtual interaction between a participant and researcher throughout a testing session. Shared presentation and computing controls can be used to deliver auditory and visual test items adapted from standard face-to-face materials or execute computer-based assessments. Spoken and manual responses can be acquired, and the components of the session can be recorded for offline data analysis. MATERIALS AND METHODS: To evaluate its feasibility, our RAND system was used to administer a speech-language test battery to 16 stroke survivors with a variety of communication, sensory, and motor impairments. The sessions were initiated virtually without prior face-to-face instruction in the RAND technology or test battery. RESULTS: Neuropsychological data were successfully acquired from all participants, including those with limited technology experience, and those with a communication, sensory, or motor impairment. Furthermore, participants indicated a high level of satisfaction with the RAND system and the remote assessment that it permits. CONCLUSIONS: The results indicate the feasibility of using the RAND system for virtual home-based neuropsychological assessment without prior face-to-face contact between a participant and researcher. Because our RAND system architecture uses off-the-shelf technology and software, it can be duplicated without specialized expertise or equipment. In sum, our RAND system offers a readily available and promising alternative to face-to-face neuropsychological assessment in stroke research.

Application and Utility of iPads in Pediatric Tele-echocardiography.

BACKGROUND: Telemedicine is used with increasing frequency to improve patient care in remote areas. The interpretation of medical imaging on iPad(®) (Apple, Cupertino, CA) tablets has been reported to be accurate. There are no studies on the use of iPads for interpretation of pediatric echocardiograms. We compared the quality of echo images, diagnostic accuracy, and review time using three different modalities: remote access on an iPad Air (iPad), remote access via a computer (Remote), and direct access on a computer linked through Ethernet to the server, the "gold standard" (Direct). MATERIALS AND METHODS: Fifty consecutive archived pediatric echocardiograms were interpreted using the three modalities. Studies were analyzed blindly by three pediatric cardiologists; review time, diagnostic accuracy, and image quality were documented. Diagnostic accuracy was assessed by comparing the study diagnoses with the official diagnosis in the patient's chart. Discrepancies between diagnoses were graded as major (more than one grade difference) or minor (one grade difference in severity of lesion). RESULTS: There were no significant differences in accuracy among the three modalities. There was one major discrepancy (size of patent ductus arteriosus); all others were minor, hemodynamically insignificant. Image quality ratings were better for iPad than Remote; Direct had the highest ratings. Review times (mean [standard deviation] minutes) were longest for iPad (5.89 [3.87]) and then Remote (4.72 [2.69]), with Direct having the shortest times (3.52 [1.42]) (p < 0.0001). CONCLUSIONS: Pediatric echocardiograms can be interpreted using convenient, portable devices while preserving accuracy and quality with slightly longer review times (1-2 min). These findings are important in the current era of increasing need for mobile health.

Structured Caregiver Feedback Enhances Engagement and Impact of Mobile Health Support: A Randomized Trial in a Lower-Middle-Income Country.

BACKGROUND: Patients' engagement in mobile health (m-health) interventions using interactive voice response (IVR) calls is less in low- and middle-income countries (LMICs) than in industrialized ones. We conducted a study to determine whether automated telephone feedback to informal caregivers ("CarePartners") increased engagement in m-health support among diabetes and hypertension patients in Bolivia. MATERIALS AND METHODS: Patients with diabetes and/or hypertension were identified through ambulatory clinics affiliated with four hospitals. All patients enrolled with a CarePartner. Patients were randomized to weekly IVR calls including self-management questions and self-care education either alone ("standard m-health") or with automated feedback about health and self-care needs sent to their CarePartner after each IVR call ("m-health+CP"). RESULTS: The 72 participants included 39 with diabetes and 53 with hypertension, of whom 19 had ≤6 years of education. After 1,225 patient-weeks of attempted IVR assessments, the call completion rate was higher among patients randomized to m-health+CP compared with standard m-health (62.0% versus 44.9%; p < 0.047). CarePartner feedback more than tripled call completion rates among indigenous patients and patients with low literacy (p < 0.001 for both). M-health+CP patients were more likely to report excellent health via IVR (adjusted odds ratio [AOR] = 2.60; 95% confidence interval [CI], 1.07, 6.32) and less likely to report days in bed due to illness (AOR = 0.42; 95% CI, 0.19, 0.91). CONCLUSIONS: In this study we found that caregiver feedback increased engagement in m-health and may improve patients' health status relative to standard approaches. M-health+CP represents a scalable strategy for increasing the reach of self-management support in LMICs.

Patient Outcomes of an International Telepediatric Cardiac Critical Care Program.

BACKGROUND: An optimal model for telemedicine use in the international care setting has not been established. Our objective was to describe variables associated with patient outcome during the implementation of an international pediatric cardiac critical care (PCCC) telemedicine program. MATERIALS AND METHODS: A retrospective review was performed of clinical records and a telemedicine database of patients admitted to the cardiac intensive care unit (CICU) at the Fundacion Cardiovascular de Colombia, Bucaramanga, Colombia, during the initial 10 months of our program, compared with patients admitted during a previous period. Information collected included demographic data, cardiac diagnosis and associated factors, Risk Adjustment for Congenital Heart Surgery (RACHS)-1 classification, and perioperative events. Primary outcome was composed of CICU and hospital mortality. Secondary outcomes were CICU and hospital length of stay (LOS). RESULTS: Of the 553 patients who were included, teleconsultation was done for 71 (12.4%), with a total of 156 encounters, including 19 for patients on extracorporeal membrane oxygenation. Three hundred twenty-one recommendations were given, and 42 real-time interventions were documented. RACHS-1 distribution was similar between study periods (p=0.427). Teleconsulted patients were significantly younger (44 versus 24 months; p=0.03) and had higher surgical complexity than nonteleconsulted patients (p=0.01). RACHS-1 adjusted hospital survival was similar between study periods. CICU and hospital LOS intervals were significantly shorter in the telemedicine period (10 versus 17 days [p=0.02] and 22 versus 28 days [p<0.001]). In surgical cases, preoperative CICU LOS was significantly shorter (3 versus 6 days; p<0.001). Variables associated with hospital mortality were higher RACHS-1 categories, lower weight, bypass time longer than 150 min, and use of circulatory arrest, as well as the presence of sepsis or necrotizing enterocolitis. Those associated with increased LOS were lower weight, extracorporeal membrane oxygenation, and cross-clamp time longer than 60 min. CONCLUSIONS: An international telemedicine service in PCCC was associated with lower CICU and hospital LOS. Prospective telemedicine interventions aimed to decrease mortality and LOS should focus on patients with higher RACHS-1 categories, lower-weight infants, and those with prolonged operative time and selective perioperative complications.

Is the digital divide an obstacle to e-health? An analysis of the situation in Europe and in Italy.

INTRODUCTION: The digital divide affecting elderly patients may compromise the diffusion of telemedicine systems for this age segment. It might be that the difficulties in the passage from trials to the effective distribution of telemedicine systems are also due to the awareness of a personal digital divide in the target population. MATERIALS AND METHODS: The analysis aims to estimate the number of people over the age of 50 years with potential cardiovascular problems able to access the Web. It made use of data from several sources (the Survey of Health, Ageing and Retirement in Europe and the Istituto Nazionale di Statistica Multiscopo Survey). Furthermore, with regard to Italy, the estimates obtained from official data were compared with those obtained in a survey investigating heart failure patients in Tuscany. RESULTS: In 2011, the percentage of people suffering from cardiovascular diseases and with Web access was 24% in Europe, with significant differences by country (ranging from 53% in Switzerland to below 20% in Italy, Spain, and Portugal). In Italy, however, the proportion of people with Web access increased from 2007 to 2011, and the survey in Tuscany showed that elderly people with limited information and communications technology skills overcame challenges and learned how to connect to the Web because they started to appreciate new technologies. CONCLUSIONS: The opportunity to use the Internet to monitor patients with chronic disease can serve as a challenge to reduce the digital divide gap and, furthermore, to increase their social and technological inclusion.