As VA experiences an influx of new veterans, research on access to care takes on increasing importance. One way to address concerns about access is via the appropriate use of telehealth/telemedicine (TH/TM) applications.

TH/TM offers a variety of advantages, but empirical studies comparing it to standard care are still in their nascent stages. In addition, applications for TH/TM vary in accordance with telecommunications technology, and have only been evaluated in a few disease states.

Emerging Evidence presents four recently completed studies that examine the role of TH/TM in care for veterans.

Keywords: Physician-patient communication, sleep apnea, congestive heart failure, dementia, caregivers.

1. Telemedicine Visits Shown to Be Less Patient Centered

Completed in October 2007, this study examined the impact of TM on communication between physician and patient. (Study No: TEL 20-036, PI: Zia Agha, MD, MS)

Questions

How do verbal and nonverbal communications during clinical TM consultation compare to in-person (IP) consults in terms of the quality of the physician-patient communication?

Results

• TM consultations were significantly shorter in duration than the IP consults.
• A second provider (nurse) was only present in TM visits but didn't contribute to the total dialogue
• Rapport building was higher during TM than in the IP visits

Implications

TM technology can impact physician-patient relationships, but further efforts to improve and use evolving TH/TM technology are required. The authors suggest that VA and/or HSR&D consider developing interventions focused on patient preparedness and patient activation to improve patient decision-making during TM visits.

2. Tele-linked Monitoring Improves Adherence in Patients with Sleep Apnea

Completed in March 2008, this study examined the impact of telecommunications linked systems (TLC) on compliance with nasal continuous positive (CPAP) pressure therapy in patients with obstructive sleep apnea syndrome (OSAS). (Study No: IIR 02-230, PI:David Sparrow, D. Sc.)

Questions

Can TLC improve patient adherence to CPAP therapy when compared with usual care?

Results

• The TLC-CPAP intervention showed higher nightly CPAP usage when compared to the control group.
• The total amount of CPAP use was predictive of improvement in quality of life as measured by the Functional Outcomes of Sleep Questionnaire; sleep symptoms, and depression.

Implications

TH/TM interventions can successfully impact quality of life, and offers an effective, low-cost, easy-to-use means of providing disease-specific education, monitoring, and counseling to improve adherence to therapies. Authors suggest further assessment of how providers use system generated reports to manage their patients, and whether the TLC intervention might improve total CPAP usage among OSAS patients.

3. Telehealth Home Care for Elderly Veterans with Congestive Heart Failure Can Lengthen Time to Readmission

Completed in January 2006, this study examined the value of TH/TM on improving access, availability, and effectiveness of care in patients with congestive heart failure (CHF). (Study No: NRI 99-345, PI: Bonnie J. Wakefield, PhD., RN)

Questions

Can a telehealth-facilitated, post-discharge support program for patients with CHF have an effective impact on: 12-month survival rates; post-discharge use of resources (readmission rates, hospital days, urgent care clinic visits, time to first readmission); and improved quality of life when compared to usual care?

Results

• Compared to usual care, the telephone or video conference intervention resulted in a longer time to readmission.
• There were no differences in hospital days or urgent care clinic use
• Study participants reported a higher disease specific quality of life

Implications

Telephone-based follow-up will have a positive impact on care for CHF patients, with TH/TM enabling earlier detection of key clinical symptoms, thus delaying the need for hospitalization. Additional research might concentrate on: learning which patients may benefit from a given mode of technology (video vs. telephone), and what dose might be considered effective for these types of interventions.

4. Testing the Effectiveness of Telephone Support for Dementia Caregivers

Caregivers of family members affected by dementia are often subject to high levels of stress. In this study, completed in September, 2008, investigators examine the impact of telephone support on caregivers. (Study No: IIR 03-287 , PI: Linda O. Nichols, Ph.D)

Questions

Can telephone support for dementia caregivers' impact their distress and concern about: their own well-being; the time they spend providing care; and, patient behaviors?

Results

• Compared to the usual care group, participants reported significantly less distress and concern over dementia-related behaviors
• Participants spent approximately 1 hour less on actual care-giving tasks
• Those who completed at least 2/3 of the intervention reported feeling significantly less burden and depression
• Unexpected result: Within the usual care group, participants reported benefits via contact with the research staff in the form of validation of their experience and feelings. This result was a byproduct of shared information collected through the assessment battery.

Implications

The study showed that the intervention was feasible for both staff and caregivers, and that increased use of telephone support groups for dementia caregivers is efficient and effective. Authors suggest that VHA clinicians may want to explore the option of instituting a general caregiver assessment or screening, if even briefly. Finally, authors believe that national or regional telephone support groups for caregivers of patients impacted by other diseases or conditions may be of considerable benefit.