Telemedicine: A Cost-Reducing Means of Delivering Psychotherapy to Rural Combat Veterans with PTSD

Leslie A. Morland, PsyD,1 Michelle Raab, MA,1,2 Margaret-Anne Mackintosh, PhD,1,2 Craig S. Rosen, PhD,3,4 Clara E. Dismuke, PhD,5,6 Carolyn J. Greene, PhD,1,7 and B. Christopher Frueh, PhD8,9

1 Pacific Islands Division, National Center for PTSD, Department of Veterans Affairs Pacific Islands Healthcare System, Honolulu, Hawaii.

2 Pacific Health Research and Education Institute, Honolulu,

3 Dissemination and Training Division, National Center for PTSD, Department of Veterans Affairs Palo Alto Healthcare System, Palo Alto, California.

4 Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California.

5 Center for Disease Prevention and Health Interventions for Diverse Populations, Ralph H. Johnson VAMC, Department of Veterans Affairs, Charleston, South Carolina.

6 Center for Health Disparities Research, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina.

7 Center for Health Care Evaluation, Department of Veterans Affairs Palo Alto Healthcare System, Palo Alto, California.

8 The Menninger Clinic, Houston, Texas.

9 University of Hawaii, Hilo, Hawaii.

All views and opinions expressed herein are those of the authors and do not necessarily reflect those of the respective institutional affiliations or the Department of Veterans Affairs.

Abstract

       Background: Although effective psychotherapies for posttraumatic stress disorder (PTSD) exist, high percentages of Veterans in need of services are unable to access them. One particular challenge to providing cost-effective psychological treatments to Veterans with PTSD involves the difficulty and high cost of delivering in-person, specialized psychotherapy to Veterans residing in geographically remote locations. The delivery of these services via clinical video teleconferencing (CVT) has been presented as a potential solution to this access to care problem. Materials and Methods: This study is a retrospective cost analysis of a randomized controlled trial investigating telemedicine service delivery of an anger management therapy for Veterans with PTSD. The parent trial found that the CVT con dition provided clinical results that were comparable to the inperson condition. Several cost outcomes were calculated in order to investigate the clinical and cost outcomes associated with the CVT delivery modality relative to in-person delivery. Results: The CVT condition was significantly associated with lower total costs compared with the in-person delivery condition. The delivery of mental health services via CVT enables Veterans who would not normally receive these services access to empirically based treatments. Additional studies addressing long-term healthcare system costs, indirect cost factors at the patient and societal levels, and the use of CVT in other geographic regions of the United States are needed. Conclusions: The results of this study provide evidence that CVT is a costreducing mode of service delivery to Veterans with PTSD relative to in-person delivery.

Key words: medicine, military medicine, telehealth, telepsychiatry

Development of a telemedicine program

A review of 1,000 videoconferencing consultations

ABSTRACT

Objective To examine the financial and organizational characteristics, demand for services, and satisfaction outcomes of a growing telemedicine program serving both urban or suburban and rural populations.

Design Retrospective review of 1,000 consecutive telemedicine consultations in the University of California (UC) Davis Telemedicine Program. 

Setting Telemedicine videoconferencing units, used to integrate care in the UC Davis Health System among the UC Davis Medical Center and several urban or suburban primary care clinics, rural hospitals, and clinic affiliates.

Subjects A total of 657 consecutive patients who consented to a telemedicine consultation.

Main outcome measures Demographic information about the patient population, the rural and urban or suburban clinics, the types of specialty consultations, and telemedicine equipment used in the UC Davis Health System. Patient and physician satisfaction were measured on a 5-point Likert scale.

Results Patients and primary care physicians reported high levels of satisfaction. Rural clinics requested more and a greater variety of specialist consultations than urban or suburban clinics.

Conclusion Although referring physicians and patients indicate a high level of satisfaction with telemedicine services and insurers are negotiating reimbursement policies, additional research must investigate the reasons why some payers, patients, and providers resist participation in these services.

Addressing health disparities in rural communities using telehealth

James P. Marcin1 , Ulfat Shaikh1 and Robin H. Steinhorn1

       The regionalization of pediatric services has resulted in differential access to care, sometimes creating barriers to those living in underserved, rural communities. These disparities in access contribute to inferior healthcare outcomes among infants and children. We review the medical literature on telemedicine and its use to improve access and the quality of care provided to pediatric patients with otherwise limited access to pediatric subspecialty care. We review the use of telemedicine for the provision of pediatric subspecialty consultations in the settings of ambulatory care, acute and inpatient care, and perinatal and newborn care. Studies demonstrate the feasibility and efficiencies gained with models of care that use telemedicine. By providing pediatric subspecialty care in more convenient settings such as local primary care offices and community hospitals, pediatric patients are more likely to receive care that adheres to evidence-based guidelines. In many cases, telemedicine can significantly improve provider, patient, and family satisfaction, increase measures of quality of care and patient safety, and reduce overall costs of care. Models of care that use telemedicine have the potential to address pediatric specialists’ geographic misdistribution and address disparities in the quality of care delivered to children in underserved communities.

A New Multidisciplinary Home Care Telemedicine System to Monitor Stable Chronic Human Immunodeficiency Virus-Infected Patients: A Randomized Study

Agathe Leo´ n1*, Ce´ sar Ca´ ceres2 , Emma Ferna ´ndez1 , Paloma Chausa2 , Maite Martin3 , Carles Codina3, Araceli Rousaud4 , Jordi Blanch4 , Josep Mallolas1 , Esteban Martinez1 , Jose L. Blanco1 , Montserrat Laguno1 , Maria Larrousse1 , Ana Milinkovic1 , Laura Zamora1 , Neus Canal5 , Josep M. Miro´ 1 , Josep M. Gatell1 , Enrique J. Go ´ mez2 , Felipe Garcı´a1

1 Infectious Diseases Unit, Hospital Clinic, Institut d’Investigacions Biome`diques August Pi I Sunyer, University of Barcelona, Barcelona, Spain,

2 Bioengineering and Telemedicine Unit, Technical University of Madrid, Madrid, Spain,

3 Pharmacy Service, Hospital Clinic, Institut d’Investigacions Biome `diques August Pi I Sunyer, University of Barcelona, Barcelona, Spain,

4 Clinical Institute of Psychiatry and Psychology, Hospital Clinic, Institut d’Investigacions Biome `diques August Pi i Sunyer, University of Barcelona, Barcelona, Spain, 5Health Economics and Outcomes Research, IMS Health, Inc., Barcelona, Spain

Abstract

Background: Antiretroviral therapy has changed the natural history of human immunodeficiency virus (HIV) infection in developed countries, where it has become a chronic disease. This clinical scenario requires a new approach to simplify follow-up appointments and facilitate access to healthcare professionals.

Methodology: We developed a new internet-based home care model covering the entire management of chronic HIVinfected patients. This was called Virtual Hospital. We report the results of a prospective randomised study performed over two years, comparing standard care received by HIV-infected patients with Virtual Hospital care. HIV-infected patients with access to a computer and broadband were randomised to be monitored either through Virtual Hospital (Arm I) or through standard care at the day hospital (Arm II). After one year of follow up, patients switched their care to the other arm. Virtual Hospital offered four main services: Virtual Consultations, Telepharmacy, Virtual Library and Virtual Community. A technical and clinical evaluation of Virtual Hospital was carried out.

Findings: Of the 83 randomised patients, 42 were monitored during the first year through Virtual Hospital (Arm I) and 41 through standard care (Arm II). Baseline characteristics of patients were similar in the two arms. The level of technical satisfaction with the virtual system was high: 85% of patients considered that Virtual Hospital improved their access to clinical data and they felt comfortable with the videoconference system. Neither clinical parameters [level of CD4+ T lymphocytes, proportion of patients with an undetectable level of viral load (p = 0.21) and compliance levels .90% (p = 0.58)] nor the evaluation of quality of life or psychological questionnaires changed significantly between the two types of care.

Conclusions: Virtual Hospital is a feasible and safe tool for the multidisciplinary home care of chronic HIV patients. Telemedicine should be considered as an appropriate support service for the management of chronic HIV infection. Trial Registration: Clinical-Trials.gov: NCT01117675.

Citation: Leo´n A, Ca´ceres C, Ferna´ndez E, Chausa P, Martin M, et al. (2011) A New Multidisciplinary Home Care Telemedicine System to Monitor Stable Chronic Human Immunodeficiency Virus-Infected Patients: A Randomized Study. PLoS ONE 6(1): e14515. doi:10.1371/journal.pone.0014515

Editor: Rupert Kaul, University of Toronto, Canada Received May 7, 2010; Accepted December 1, 2010; Published January 21, 2011

Copyright: © 2011 Leo ´n et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: Dr. Leo ´n is supported by Contract CM06/00170 from the Institut de Investigacions Biome `diques August Pi I Sunyer and Fundacio ´ Clı´nic in collaboration with the Spanish Health Department. The role of Health Economics and Outcomes Research IMS Health in the study had been only to analyze the patients’ quality of life data. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests: A Leo ´n, C Ca ´ceres, E Ferna ´ndez, P Chausa, M Martin, C Codina, A Rousaud, A Milinkovic, M Laguno, M Larrousse, L Zamora, and EJ Go ´mez have no potential conflicts of interests. Neus Canal is employed by a commercial company, Health Economics and Outcomes Research IMS Health. E Martinez, F Garcı´a, J Blanch and JL Blanco have received research grants from Abbott, Bristol-Myers Squibb, and Gilead Sciences. J Mallolas and JM Miro have received research grants from Abbott, Boehringer-Ingelheim, Bristol-Myers Squibb, Gilead Sciences and Roche. JM Gatell has received honoraria or research grants from Bristol-Myers Squibb, MSD, GlaxoSmithKline, Gilead Sciences, Tibotec, Roche, Boehringerngelheim, Abbott and Pfizer. This does not alter our adherence to all the PLoS ONE policies on sharing data and materials."

Telemedicine and burns: an overview