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ACC 97-013 – HSR&D Study

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ACC 97-013
Pressure Ulcer Assessment via Telemedicine
Julie C. Lowery PhD MHSA
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Funding Period: October 1998 - September 2000

BACKGROUND/RATIONALE:
A Web-based telemedicine system for monitoring the status of patients with pressure ulcers has been developed. It consists of three major data collection components: (1) digital photograph of ulcer; (2) quantitative measurements of wound status (i.e., ulcer area and volume, skin elasticity); and (3) other wound and patient data collected by a nurse. Data are collected via laptop computer and transmitted to a central database, where a computer program transforms the data into the necessary reporting format. The output is posted onto a World Wide Web page for access by the consulting physician. The system incorporates all data requirements for assessment recommended by AHCPR's Clinical Practice Guideline, Treatment of Pressure Ulcers.

OBJECTIVE(S):
The primary objective of this pilot study was to evaluate the clinical accuracy of a telemedicine system for assessing the status of pressure ulcers, both chronic and those which have been surgically repaired. The principal hypotheses were: (1) use of the telemedicine system results in the same diagnoses as does in-person patient assessment; and (2) patients are satisfied with the telemedicine system.

METHODS:
Two VA medical centers and two specialties participated in the study: Ann Arbor (plastic surgery) and Augusta (plastic surgery, physical medicine and rehabilitation). They contributed inpatients and outpatients with a pressure ulcer of stage II, III, or IV over a one-year enrollment period. All study patients were assessed both in-person (the "gold standard") and with the telemedicine system. The in-person and telemedicine physicians provided yes/no responses to four diagnostic questions concerning wound healing and infection, based on AHCPR guidelines, and they were blinded to each other’s assessments. Patient satisfaction data were collected using a specially designed, self-administered questionnaire to measure perceptions regarding the burden of the telemedicine system, confidence in the evaluation, and absence of direct contact with a physician.

FINDINGS/RESULTS:
A total of 105 patients were enrolled in the study, with data collected on 430 visits. Results of a preliminary analysis conducted in July 2000 showed the rates of agreement between the participating physical medicine and rehabilitation physicians on assessment of chronic pressure ulcers were 64.2 percent (N=95 visits) for "Is the wound healing?"; 67.3 percent (N=150) for "Is necrotic tissue present?"; and 95.7 percent (N=161) for "Is cellulitis suspected?". Rates of agreement between the participating plastic surgeons (Ann Arbor) on assessment of chronic pressure ulcers were 59.0 percent (N=83 visits) for healing; 76.5 percent (N=136) for necrosis; and 79.4 percent (N=136) for cellulitis. Rates of agreement between the participating plastic surgeons (Augusta) on assessment of pressure ulcers that had been surgically repaired were 93.2 percent (N= 88) for necrosis and 92.1 percent for cellulitis (n=89). When compared with "baseline" % agreement (i.e., agreement between the same physicians when both assessed a different sample of patients in person), these rates of agreement are significantly lower for the PM&R physicians when identifying necrosis, and for the plastic surgeons (chronic wounds only) for healing and cellulitis. (No baseline data are available for assessment of surgically repaired ulcers.) Sensitivity and specificity analyses will be performed. A link to a demonstration web site of the system can be found under "Telemedicine Projects" at: http://www.hsrd.ann-arbor.med.va.gov/.

IMPACT:
Findings from this pilot study will be used to design and implement a telemedicine system for improving access to specialty care for bed-ridden and spinal cord injury patients.

PUBLICATIONS:

Journal Articles

  1. Wilkins EG, Lowery JC, Goldfarb S. Feasibility of virtual wound care: a pilot study. Advances in Skin and Wound Care. 2007 May 1; 20(5):275-6, 278.
  2. Kim HM, Lowery JC, Hamill JB, Wilkins EG. Patient attitudes toward a web-based system for monitoring chronic wounds. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2004 Nov 1; 10(2 Suppl):S26-S34.
  3. Roth RS, Lowery JC, Hamill JB. Assessing persistent pain and its relation to affective distress, depressive symptoms, and pain catastrophizing in patients with chronic wounds: a pilot study. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists. 2004 Nov 1; 83(11):827-34.
  4. Kim HM, Lowery JC, Hamill JB, Wilkins EG. Accuracy of a web-based system for monitoring chronic wounds. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2003 Jun 1; 9(2):129-40.
  5. Lowery JC, Hamill JB, Wilkins EG, Clements E. Technical overview of a web-based telemedicine system for wound assessment. Advances in Skin and Wound Care. 2002 Jul 1; 15(4):165-6, 168-9.
Reports

  1. Lowery J. Pressure Ulcer Assessment via Telemedicine. 2002 Oct 1.
Conference Presentations

  1. Lowery JC. Applications of the preventative health care model to wound care-secondary prevention: novel clinical methods (expert lecture session). Paper presented at: Evidence-Based Practice in Wound Care Annual Conference; 2006 Sep 15; Cleveland, OH.
  2. Wilkins E, Lowery JC, Goldfarb S. Feasibility of virtual wound care. Paper presented at: American Telemedicine Association Annual Meeting; 2005 Apr 1; Denver, CO.
  3. Lowery J, Kim HM, Wilkins E, Hamill JB. Accuracy of Web-based telemedicine system for monitoring ulcers. Paper presented at: VA HSR&D National Meeting; 2002 Oct 1; Washington, DC.
  4. Lowery JC, Wilkins EG, Hamill JB. A store-and-forward system for assessment of pressure ulcers. Paper presented at: American Telemedicine Association Annual Meeting; 2001 Jun 3; Fort Lauderdale, FL.
  5. Harris A, Lowery JC, Hamill JB, Rees RS, Wilkins EG. Telemedicine assessment of chronic wounds. Paper presented at: Michigan Academy of Plastic Surgeons Annual Meeting; 2000 Jul 23; Mackinac Island, MI.


DRA: Aging, Older Veterans' Health and Care, Health Systems
DRE: Diagnosis
Keywords: Access, Telemedicine
MeSH Terms: Telemedicine

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