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JGIM Supplement Highlights VA’s Unique Advances in Virtual Care
This supplemental issue of the Journal of General Internal Medicine (JGIM) describes opportunities to advance VA virtual care research and presents a collection of articles reporting on novel virtual care research and evaluation initiatives across the healthcare system.
Date: March 13, 2024
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Significant Increase in Telehealth for Primary Care among Homeless Veterans Following the Pandemic
This study sought to examine the extent to which homeless-experienced Veterans used telehealth services in primary care – and to characterize users before and after the onset of the pandemic. Findings showed that despite decreased access to health information technology and low pre-pandemic telehealth use, Veterans experiencing homelessness sustained a high use of telehealth in primary care post-pandemic: 1 in 5 Veterans experiencing homelessness participated in video visits, and the majority contacted their primary care teams by phone. High telehealth use was also maintained beyond the first year of COVID-19. For example, compared to pre-pandemic, telehealth use increased substantially two years post-pandemic (video: 1% versus 21%; phone: 61% versus 77%). Women and racial-ethnic minorities had higher video uptake proportionately, suggesting that telehealth may address access disparities among these homeless-experienced patient groups.
Date: January 22, 2024
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Team-Based Palliative Telecare Led to Improved Quality of Life in Veterans with Chronic Lung Disease and Heart Failure
This clinical trial determined the effect of a nurse and social worker palliative telecare team on quality of life in outpatient Veterans with COPD, heart failure (HF), or interstitial lung disease (ILD) compared to usual care. Findings showed that Veterans who received the palliative telecare team intervention reported significantly improved quality of life at six months compared with Veterans who received usual care (mean quality of life score improvement of six points vs. one point; a clinically meaningful difference is four points). The positive intervention effect on quality of life began early, at 4 months, and persisted at 12 months. The intervention also improved COPD and HF health status, and depression and anxiety at six months. The virtual and population approach of this intervention can improve the reach of palliative care services in traditionally under-resourced areas.
Date: January 16, 2024
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Rural-Urban Telemedicine Disparity among Veterans Worsens Following Onset of COVID-19 Pandemic
This study examined changes over time in rural-urban differences in telemedicine use for primary care and mental health integration services among nearly 64 million primary care and 4 million mental health integration visits. Findings showed that the pandemic exacerbated the rural-urban telemedicine divide across VA, possibly because underlying causes of digital inequity were not addressed as initiatives to expand telemedicine use across VA were instituted. Prior to the pandemic, telemedicine use for primary care services was higher at rural VA healthcare systems than urban ones (34% vs. 29%). Following the onset of the pandemic, usage rates switched (55% vs. 60%). The rural-urban telemedicine gap was even larger post pandemic for mental health integration than for primary care services, with unadjusted analyses showing 76% rural vs. 84% urban telemedicine use. Future telemedicine research, implementation efforts, and policy must address rural-urban structural disparities (e.g., internet bandwidth) and possibly tailor technology to encourage telemedicine adoption among rural users at the patient, provider, and healthcare system level.
Date: March 7, 2023
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VA Treatment of Opioid Use Disorder was Maintained During the COVID Pandemic Through Rapid Shift to Telehealth
At the beginning of the COVID pandemic, key federal policy changes were implemented to decrease barriers to telehealth-delivery of buprenorphine, a life-saving medication treatment for patients with opioid use disorder (OUD). This study examined the impact of these COVID-19 policies on buprenorphine treatment across different modalities (telephone, video, and in-person visits). Findings showed that buprenorphine treatment for OUD was maintained during the COVID-19 pandemic – across the VA healthcare system – through a rapid shift to telehealth, at a time when other healthcare delivery decreased. The number of Veterans receiving buprenorphine increased from 13,415 in March 2019 to 15,339 in February 2021. By February 2021, phone visits were used by the most patients (50%), followed by video (32%) and in-person (17%). Among Veterans receiving a buprenorphine treatment visit each month, the proportion of telehealth visits (phone and video) increased dramatically from 12% in March 2019 to 83% in February 2021. The proportion of Veterans reaching 90-day retention on buprenorphine treatment decreased significantly from the pre- to post-pandemic periods (50% to 48%), but days on buprenorphine increased significantly from 204 to 209. Policy changes that were rapidly implemented to reduce barriers to telehealth allowed continued delivery of buprenorphine treatment. Future changes to these policies (e.g., reversing support for telehealth prescribing of buprenorphine) could have major implications for patient care.
Date: July 28, 2022
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Characteristics of the Rise in Telehealth During COVID Pandemic
This study sought to examine patient, provider, and site-level characteristics of any virtual and video-based care in primary care (PC). Findings showed that before the onset of COVID-19, only 14% of PC patients used any telehealth services, and only 0.3% used video-based care. However, during the first 12 months of COVID-19, 63% of patients used telehealth services, and 11% used video-based care. Veterans at community-based clinics had a higher percentage of any telehealth use (38%) compared to Veterans receiving primary care at the main medical facility (30%). Conversely, video use was lower among community-based PC patients (10%) compared to PC patients at the medical facility (13%). Social workers, nutritionists, and pharmacists had the highest percentage of telehealth use (54%, mostly telephone) compared to primary care providers (34%), whereas mental healthcare providers were more likely to provide video-based care (43%) compared to PC clinicians (15%). Among all age groups except the oldest (75+), women were more likely to use telehealth or video. Additional research is needed to identify which PC outpatient services are better suited for telephone (e.g., case management) vs video-based care (e.g., integrated mental health visits).
Date: June 18, 2022
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Genetic Consultation Provided by VA Facilities or Centralized VA Virtual Care More Timely and Better Coordinated than Community Care Options
This study assessed care coordination and equity in the delivery of genetic care for the care models available to VA patients (i.e., VA-traditional, centralized VA-telehealth, and non-VA care). Findings showed that VA genetic care models – both traditional and centralized telehealth – had better care coordination than non-VA care. Veterans referred to non-VA care completed their consult only 57% of the time compared with 75% if referred to the VA-traditional model and 73% with the centralized VA-telehealth model. Completion of a genetic consultation if referred to non-VA care was almost 3 times longer than with either VA model (140 days vs 55 days for VA-traditional and 45 days for VA-telehealth). The centralized VA-telehealth model was associated with exacerbated healthcare disparities based on self-reported race or ethnicity and gender compared with the VA traditional model. Veterans reporting their race as Asian, American Indian, Alaskan Native, Hawaiian and other Pacific Islander, and unknown were 46% less likely to be referred to the centralized VA-telehealth model compared to the VA-traditional model. Black Veterans were significantly less likely to complete a consultation compared to White Veterans, but only if referred to the centralized VA-telehealth model. Women Veterans were 50% more likely to be referred to the centralized VA-telehealth model than the VA traditional model. VA should assess structural barriers to using centralized telehealth services and the needs and preferences of vulnerable subpopulations in order to find solutions that mitigate health disparities and improve access.
Date: April 11, 2022
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Shift to Virtual Visits for Veterans with Type 2 Diabetes During the Pandemic Was Not Associated with Adverse Outcomes
This study sought to describe the changes in management, control, and outcomes in older people with type 2 diabetes (T2D) associated with the shift from in-person to virtual visits. Findings showed that despite a shift to virtual visits and decreased A1c measurement rates during the pandemic, no association with A1c level or short-term T2D-related outcomes (i.e., ER visit or hospitalization for hypo or hyperglycemia) was observed, providing some reassurance about the adequacy of virtual visits. Relative to baseline, among the 740,602 Veterans in this study, there were 55% fewer in-person visits and 824% more virtual visits, with a net result of 10% more total visits during the pandemic relative to the pre-pandemic period. There also were 6% fewer A1c measurements, and 14% more treatment intensifications.
Date: January 6, 2022
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Important IT Issues Impede Implementation of VA Mobile Teledermatology Application
To improve access to teledermatology for Veterans, VA created the web-based VA Telederm application (app), which interfaces with the EHR (electronic health record). This study evaluated the initial implementation process for the VA Telederm app – and assessed organizational readiness for change (ORC). Findings showed that at all sites, technical issues including sub-optimal information technology infrastructure negatively affected adoption, leading to the inoperability of the app at two sites. There also were technical inefficiencies related to users’ unfamiliarity with new devices and inconsistent Internet access. Each site had a high level of organizational commitment for change, including support from leadership and clinical champions, but this was insufficient to surmount the technological barriers. Communication and early-user involvement encouraged individual and system-wide adoption. Thus, information obtained from users at an early stage of implementation provided an understanding of needed communication strategies. Leadership support, commitment to change, staff perceptions about the value of a change and their ability to implement it, and a clinical champion were important for implementation effectiveness, but were not enough to overcome technological barriers.
Date: March 1, 2021
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Accelerating Implementation of VA Virtual Care
In December 2019, HSR&D investigators hosted a four-hour Think Tank, Accelerating Implementation of Virtual Care in VHA Practice, to: a) examine current virtual care research and practice; b) consider challenges to virtual care research across VA; c) discuss novel approaches to using and evaluating virtual care; and d) assess perspectives of virtual care from a variety of stakeholders. Think Tank attendees identified an initial list of 15 potential priorities and narrowed these down to four: 1) scaling evidence-based practices, 2) centralizing virtual care, 3) creating high-value care within VHA with virtual care, and 4) identifying appropriate patients for virtual care. The Think Tank took an important step in setting a partnered research agenda to optimize the use of virtual care within VHA. In doing so, investigators learned that clarifying who “owns” virtual care is essential to its success, and creating a faster pipeline of inception to implementation can help to align aims and timelines for research and operations.
Date: January 26, 2021
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Veterans Participating in a VA National Telehealth Tablet Initiative Save Both Time and Money
In 2016, VA initiated a program to distribute video-enabled tablets to Veterans with geographic, clinical, and/or social access barriers to in-person care so that they could receive services in their homes or other convenient locations. As part of a national evaluation of this initiative, a patient experience survey was conducted with a subset of tablet recipients. Investigators in this study sought to determine patient-reported monetary and time savings, as well as characteristics associated with those savings. Findings showed that 92% of respondents reported that the tablets saved them money or time; 89% reported saving money, and 71% reported saving time. Among those who reported monetary savings, 41% reported saving $25-50 and 31% reported saving >$50 per appointment. Monetary savings were most pronounced among Veterans living a greater distance from VA or experiencing travel barriers and those without mental health conditions.
Date: December 26, 2019
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Video Telehealth Tablet Initiative Improves Access to and Continuity of Mental Healthcare for Veterans
In 2016, VA initiated a program to distribute video-enabled tablets to Veterans with geographic, clinical, or social access barriers to in-person care so that they could receive services in their homes or other convenient locations: 75% of tablet recipients had a mental health diagnosis, providing a unique opportunity to assess the effectiveness of this national dissemination of tablets. Findings showed that distributing the tablets to Veterans with mental health conditions appeared to improve access to and continuity of mental health services while also improving clinical efficiency. Compared to the control group, tablet recipients experienced an increase of 1.9 psychotherapy encounters; an increase of 1.1 medication management visits; a 19% increase in their likelihood of receiving recommended mental healthcare continuity; and a 20% decrease in their missed opportunity rate (i.e., missed appointments) six months post-tablet receipt.
Date: August 5, 2019
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Most Women Veterans Report Timely Access to Mental Healthcare, Leading to High Satisfaction with VA Care
This study evaluated access to mental healthcare by assessing women Veterans’ perceptions of the timeliness and quality of care. Findings showed that of the 419 women Veterans in this study cohort, 59% reported "always" getting an appointment for mental healthcare as soon as needed, and another 22% reported “usually” getting an appointment as soon as needed. Two problems were negatively associated with timely access to mental healthcare: 1) medical appointments that interfere with other activities, and 2) difficulty getting questions answered between visits. Average ratings of the quality of VA healthcare were high: 8.5 out of 10 regarding VA mental healthcare, 8.7 for VA primary care, and 8.2 for VA healthcare overall. Moreover, 93% of women Veterans reported that they would recommend VA healthcare to other women Veterans. This study highlights opportunities for addressing barriers to timely mental healthcare through practices such as non-traditional clinic hours, open access scheduling, telemedicine, and secure messaging.
Date: April 5, 2018
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Evaluating Patient-Mediated Health Information Exchange
In 2013, VA’s Office of Rural Health and the Department of Health and Human Services (Office of the National Coordinator) partnered to promote the use of My HealtheVet’s Blue Button capability to facilitate the transfer of Veterans’ health information to non-VA providers to improve care coordination for Veterans living in rural settings who use both VA and non-VA care (dual users). This partnership resulted in the Veteran-Initiated Electronic Care Coordination pilot study, which sought to: 1) train rural-dwelling dual-use Veterans to use Blue Button capabilities to share their health information with non-VA providers, and 2) evaluate whether or not the availability of VA information during community clinical encounters impacted the care they received. Findings from this study showed that with brief training, Veterans were able to generate their Continuity of Care Document (CCD) in My HealtheVet, share it with non-VA providers, and benefit from improved communication about medications and reduced laboratory duplication. After training, 78% of Veterans reported that the CCD would help them be more involved in their healthcare, and 86% planned to share it regularly with non-VA providers. The majority of non-VA providers (97%) were confident in the accuracy of the information, and 96% wanted to continue to receive the CCD. Moreover, 50% of non-VA providers reported that they did not order a laboratory test or other procedure because of CCD information.
Date: October 11, 2016
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Telemedicine-Based Intervention Improves Outcomes for Veterans with Poorly Controlled Diabetes
Investigators in this pilot trial developed the Advanced Comprehensive Diabetes Care (ACDC) intervention, which bundles four evidence-based telemedicine approaches – telemonitoring, self-management support, medication management, and depression management – and is designed for practical delivery by existing VA Home Telehealth program nurses using standard VA equipment. Findings showed that the ACDC intervention significantly reduced HbA1c by 1.0% versus usual care. Veterans receiving ACDC had significantly better diabetes self-care at six months versus usual care, but depressive symptoms did not differ between groups. Although ACDC did not address hypertension, Veterans in the intervention group had significantly lower systolic and diastolic blood pressure versus usual care. By utilizing Home Telehealth infrastructure that is ubiquitous at VA centers nationwide, ACDC represents a potentially scalable approach to reducing the burden of diabetes within VA.
Date: November 5, 2015
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Telemedicine-Delivered Psychotherapy for Older Veterans with Depression as Effective as In-Person Psychotherapy
This study assessed the efficacy of psychotherapy delivered to older Veterans via telemedicine in their homes. Findings showed that telemedicine-delivered psychotherapy for older Veterans with major depression produced outcomes that were no worse than in-person treatment delivery. Treatment response did not differ significantly between the telemedicine and same-room therapy groups on any of the instruments used. A high proportion of Veterans were rural residents (71%) and average session attendance was high (81% of Veterans in the telemedicine group completed all 8 sessions as did 79% of Veterans in the same-room group).
Date: August 1, 2015
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Telemedicine-based Collaborative Care Intervention Improves PTSD Outcomes among Veterans Residing in Rural Settings
This trial sought to test a collaborative care model designed to improve access to and engagement in evidence-based psychotherapy and pharmacotherapy for Veterans with PTSD living in rural settings. Findings showed that telemedicine-based collaborative care successfully engaged Veterans who lived in rural settings in evidence-based psychotherapy to improve PTSD outcomes. During the 12-month study period, 55% of Veterans randomized to the Telemedicine Outreach for PTSD (TOP) intervention received Cognitive Processing Therapy (CPT) compared to 12% of Veterans who were randomized to usual care. Veterans randomized to TOP had 18 times higher odds of initiating CPT and 8 times higher odds of completing >8 sessions (considered the minimally therapeutic dosage). Veterans in the TOP group had significantly larger decreases in PTSD symptoms compared to Veterans in the usual care group – a 5.31 decrease in symptom severity on the Posttraumatic Diagnostic Scale at six months, on average, compared to 1.07 for Veterans in usual care (a 5-point decrease in the Scale represents a decrease in frequency from 2 to 4 times a week to once a week for 5 symptoms of PTSD). The TOP group had significantly greater reductions in depression symptom severity compared to usual care at both six and twelve months.
Date: November 19, 2014
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Implementation of Telemedicine in VA ICUs May Not Reduce Mortality Rates or Length of Hospital Stays
This study evaluated the impact of telemedicine (TM) implementation on short-term (ICU and in-hospital) and longer-term (30-day) mortality rates and length of stay (LOS) within a regional network of seven Midwest VA hospitals. Findings showed that the implementation of an ICU telemedicine program did not reduce mortality rates or length of hospital stay. It was not associated with a significant decline in ICU, in-hospital, or 30-day mortality rates or LOS in unadjusted or adjusted analyses.
Date: May 12, 2014
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PTSD Treatment via Video-Teleconferencing as Effective as In-Person Treatment
This study is the first randomized controlled trial to compare the efficacy of delivering “cognitive processing therapy-cognitive only” (CPT-C) via video-teleconferencing (VTC) to in-person delivery among a sample of rural Veterans. Findings showed that the use of clinical video-conferencing services to provide CPT-C therapy to Veterans with PTSD who lived in rural settings was as effective as face-to-face treatment. Significant reductions in PTSD symptoms were identified at post-treatment and 3- and 6-month follow-ups. High levels of therapeutic alliance, treatment compliance, and satisfaction, and moderate levels of treatment expectancies were reported, with no differences between groups. VTC technology evidenced very few disruptions, and no sessions were canceled due to technological difficulties. There were no adverse events associated with delivering CPT-C through videoconferencing.
Date: May 1, 2014
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Telemental Health Expands in VA between 2006-2010
This is the first large scale study to describe the types of telemental health services provided by the VA healthcare system. Findings show that each type of telemental health encounter increased substantially across the five years; for example, the number of encounters for medication management increased from 13,466 in FY06 to 32,284 in FY10, representing a 140% increase over the five-year period. Psychotherapy with medication management was the fastest growing type of telemental health service, increasing from 14,188 encounters in FY06 to 45,107 encounters in FY10, a 218% increase. The use of videoconferencing technology has expanded beyond medication management alone to include telepsychotherapy services (individual and group psychotherapy) and diagnostic assessments. The increase in telemental health services is encouraging, given the large number of returning Veterans who live in rural areas and may have difficulty accessing mental healthcare.
Date: November 1, 2012
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Veterans’ Communication Preferences for Primary Care Needs
Overall, 54% of the Veterans in this study reported being regular computer users (daily, 2-3 times per week, or once per week). On average, a greater proportion of infrequent users (2-3 times per month, less than once per month, or do not typically use a computer) were male, older, and in fair/poor health compared to regular users. Among Veteran primary care patients, telephone communication was preferred for the majority of primary care issues, including general medical questions, medication questions and refills, as well as preventive care reminders, scheduling, and test results. In-person visits were preferred for new medical conditions, concerns about ongoing conditions, treatment instructions, and information about next steps in care. Of regular computer users, about 1/3 preferred electronic communication (email or Internet portal, including MyHealtheVet) for preventive care reminders (37%), test results (34%), and prescription refills (32%). Veterans who used the Internet did so for a variety of reasons, with e-mail (85%) and accessing health information (39%) among the top two.
Date: September 1, 2012
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Racial Differences in Outcomes of VA Telephone-Delivered Hypertension Disease Management Program
A combination of home BP monitoring, remote medication management, and telephone-tailored behavioral self-management appears to be particularly effective for improving BP among African American Veterans. However, the effect was not seen among non-Hispanic white Veterans.
Among African Americans, improvement in mean systolic BP was greatest for those receiving the combined intervention: compared to usual care, systolic BP was 6.6 mmHg lower at 12 months and 9.7 mmHg lower at 18 months. These decreases in BP were not seen in non-Hispanic white Veterans.
Date: August 3, 2012
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No Significant Cost Increase for Telephone-based BP Intervention for Veterans with Hypertension
Average intervention costs were similar in the three study arms, and at 18 months there were no significant differences in direct VA medical costs or total VA costs between treatment arms and usual care. Mean total VA costs per patient in the treatment arms were $14,441 for behavioral management; $14,453 for medication management; $13,009 for combined treatment; and $12,328 for usual care. The combined intervention resulted in observed net savings in outpatient care and overall medical care, as well as the lowest mean cost difference and total cost, but these differences were not statistically significant relative to the other intervention arms. Patients in all three intervention arms incurred $289 to $1,127 less in outpatient care compared to those treated under usual care, but these savings were not statistically significant.
Date: June 1, 2012
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TeleRehab Improves Physical Function in Veterans with Stroke
This trial sought to determine the effects of a multi-faceted Stroke Tele-Rehabilitation (STeleR) intervention on physical function, and secondarily on disability, in community-dwelling Veterans who had experienced a stroke within the past two years. The STeleR intervention significantly improved lower body physical functioning in Veterans with stroke. Most gains in physical functioning and other improvements occurred during the initial 3 months of the study, but were maintained during the subsequent 3 months during which no STeleR services were provided. The STeleR intervention also improved Veterans’ ability to perform life tasks such as “take part in regular fitness program” and management of social tasks that involve minimal mobility or physical activity, such as “take care of own health.” The authors suggest the STeleR intervention could be a useful supplement to traditional post-stroke rehabilitation given the limited resources available for in-home rehabilitation for stroke survivors.
Date: May 24, 2012
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VA HIV and Hepatitis C Telemedicine Clinics Improve Patient Outcomes among Rural Veterans
Among a rural-dwelling study sample, HIV and hepatitis C telemedicine clinics were associated with improved access, high patient satisfaction, and a reduction in health visit-related time. Clinic completion rates (proxy for access) were higher for telemedicine (76%) than for in-person visits (61%). Of the 43 Veterans in the study, 30 (70%) completed a telemedicine-facilitated survey. More than 95% of these Veterans rated telemedicine at the highest level of satisfaction and preferred telemedicine to in-person visits. Veterans estimated that total health visit time was 340 minutes less for telemedicine compared to in-person visits. The majority of perceived time reduction was related to travel.
Date: April 1, 2012
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Low Proportion of Veterans Are Using My HealtheVet to Transfer or Share Information with Others
Of the 25,898 Veterans who participated in Wave One of the study (asking about the transfer of information from My HealtheVet to other places/persons), 40% reported printing information, 21% reported saving information electronically, and 4% sent information from My HealtheVet to another person. Of the 18,471 Veterans who participated in Wave Two of the study (asking about using and sharing the My HealtheVet medication information list), 30% reported self-entering medication information into My HealtheVet, with 60% of those reporting sharing their complete medication list with their VA providers and 32% with their non-VA providers.
The authors suggest that although some Veterans are transferring important medical information from their personal health records, increased education and awareness is needed to help them use this information to improve continuity of care with their providers, both VA and non-VA.
Date: January 1, 2012
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Telemedicine-Based Collaborative Care Intervention for Depression has Greater Effect on Minority vs. White Veterans
The Telemedicine Enhanced Antidepressant Management (TEAM) study was a randomized trial of telemedicine-based collaborative care tailored for small, rural primary care practices. Investigators in the current study evaluated racial differences in clinical outcomes among 360 Veterans with depression who were randomized to usual care or the TEAM intervention. Findings showed that in the usual care group, minority Veterans had a lower treatment response rate (8%) than Caucasians (18%), but this was not significant. In contrast, minority Veterans in the TEAM intervention group had a significantly higher treatment response rate (42%) than Caucasians (19%) in the intervention group. Veterans in the minority group were significantly less likely to report that antidepressants were an acceptable form of treatment, and were significantly less likely to have had prior or current depression treatment. However, none of these variables were significantly related to treatment outcomes. Thus, the study was not able to determine why minorities responded better to the intervention than Caucasians.
Date: November 1, 2011
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Growing VA Research Agenda for Women Veterans
This paper reports on the 2010 VA Women’s Health Services Research Conference, as well as the resulting research agenda for moving forward on behalf of women who have served in the military. Recommendations for the future VA women’s health research agenda, resulting from this conference, included, to name a few: Address gaps in women Veterans’ knowledge and use of VA services (e.g., outreach/education, social marketing, telemedicine); Evaluate and improve quality of transitions from military to VA care; Assess gender differences in the presentation and outcomes of chronic diseases; Determine reproductive health needs of women Veterans; Examine the structure and care models that support patient-aligned care teams; Evaluate variations in mental healthcare needs; Assess and reduce the risk of homelessness among women Veterans; Conduct research on post-deployment reintegration and readjustment among women Veterans; and Develop combat exposure measure(s) that reflect women Veterans’ experiences.
Date: July 6, 2011
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Telemedicine-Based Collaborative Care Does Not Increase Total Workload for Primary Care or Mental Health Providers
This study examined patterns of healthcare utilization and cost associated with telemedicine-based collaborative care for depression among Veterans who received care in seven VA community-based outpatient clinics (CBOCs). Findings suggest that telemedicine-based collaborative care does not increase total workload for primary care or mental health providers; therefore, there is no disincentive for mental health providers to offer telemedicine-based care ? or for primary care providers to refer Veterans to telemedicine care. There was no significant difference in the total number or cost of primary care encounters between Veterans in the intervention group and those in the usual care group. Between the two groups, there also were no statistically significant differences in total mental health encounters or cost; however, Veterans in the intervention group did have significantly more cost and encounters in specialty physical health clinics. In addition, Veterans in the intervention group had a significantly greater total outpatient cost compared to Veterans in usual care. These differences were likely due to the high levels of physical and mental health comorbidities in this study population.
Date: May 26, 2011
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Telemedicine ICU Coverage Lowers ICU Mortality but Not In-Hospital Mortality
Because many hospitals lack the patient volume or financial resources to hire dedicated specialists trained to care for critically ill patients (intensivists) – and because of a shortage of these trained specialists – hospitals are increasingly adopting telemedicine ICU (tele-ICU) coverage. This systematic review of the literature examined the impact of tele-ICU coverage on mortality and length of stay in non-VA hospitals. Findings showed that tele-ICU coverage was associated with a significant 20% reduction in ICU mortality, but did not significantly reduce in-hospital mortality for patients admitted to an ICU. Tele-ICU coverage was associated with a 1.26 day mean reduction in ICU length of stay, which translates into a 10%-30% relative reduction in ICU length of stay. Tele-ICU was not associated with a reduction in the patient’s length of stay in the hospital.
Date: March 28, 2011
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Telephone-based Care Coordination Intervention Complements Care for Veterans with Dementia and Supports their Caregivers
This article provides a detailed description of a telephone-based care coordination intervention – Partners in Dementia Care (PDC) – developed for Veterans with dementia and their family caregivers across all stages of the disease. Findings show that, overall, the PDC intervention addresses the diverse needs of Veterans with dementia and their caregivers, including non-medical care issues such as understanding VA benefits, accessing community resources, and addressing caregiver strain. The authors also note that the PDC intervention incorporates several unique features that distinguish it from most other services and programs for dementia caregiving, such as the delivery of the intervention through formal partnerships between VAMCs and local Alzheimer’s Association Chapters, the inclusion of family caregivers, and the breadth of issues addressed for both Veterans and their caregivers. The consumer-directed philosophy of the program enabled Care Coordinators to serve a large number of families in a cost-efficient way, since Veterans and families were taking action on their own with support and guidance from both VA and Alzheimer’s Association care coordinators.
Date: January 17, 2011
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Telephone-Based Self-Management Program Improves Pain among Veterans with Osteoarthritis
This study examined the effectiveness of a one-year, telephone-based self-management support intervention for 461 Veterans with symptomatic hip and/or knee osteoarthritis who received VA primary care at the Durham VAMC. Findings show that the telephone-based self-management program produced moderate improvements in pain among Veterans with osteoarthritis, particularly compared with a general health education intervention. The self-management group also had greater improvement on the walking and bending subscale measure.
Date: November 2, 2010
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Evidence Review Suggests Clinic Dermatology Provides Better Accuracy than Teledermatology
This systematic review of the scientific literature sought to compare teledermatology and clinic dermatology in several key areas: diagnostic accuracy/concordance, management accuracy/concordance, clinical outcomes, and costs. Of the 78 studies included in this review, about two-thirds comparing teledermatology and clinic dermatology found better diagnostic accuracy with clinic dermatology. Diagnostic concordance between store-and-forward and clinic dermatology was fair. Concordance rates between real-time or live teledermatology compared to clinic dermatology were higher, but were based on fewer patients. Overall rates of management accuracy were equivalent, but teledermatology was inferior to clinic dermatology for malignant lesions. Management concordance was fair to excellent. There was insufficient evidence to evaluate clinical course outcomes, but patient satisfaction and preferences were comparable. Teledermatology did reduce time to treatment and clinic visits, and it was cost-effective – if certain assumptions were met (i.e., patient travel distance, costs of clinic dermatology).
Date: October 29, 2010
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Therapy via Video-Teleconference as Effective as In-Person Treatment in Reducing Anger Problems in Veterans with PTSD
Cognitive behavioral therapy (CBT) anger management conducted via video-teleconference was as effective as in-person delivery of the same treatment in reducing anger problems among Veterans with PTSD who live in rural settings. Moreover, mean improvements in the video-teleconferencing group were actually slightly larger than in the in-person treatment group. Veterans in both treatment groups benefited from anger management therapy (AMT), making this one of the few large randomized controlled trials to show meaningful benefits for reducing anger problems in Veterans with PTSD. Veterans in both treatment groups reported high rates of treatment credibility, satisfaction with care, homework adherence, and high alliance with the therapist.
Date: January 26, 2010
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Long-Term Impact of Home Telehealth on Preventable Hospitalizations for Veterans with Diabetes
This study assessed the longitudinal effect of a VA Care Coordination Home Telehealth (CCHT) program on preventable hospitalizations for Veterans with diabetes. Findings showed a statistically significant reduction in preventable hospitalizations for Veterans enrolled in the CCHT program during the initial 18 months of follow-up compared to Veterans in the control group, even after adjusting for potential socio-demographic and clinical risk factors. However, the program did not demonstrate a significant impact after the initial 18 months, which may largely be due to the fact that the control group had more deaths than the CCHT group during those 18 months, likely resulting in the control group’s decreased use of preventable hospitalizations during the remainder of the study period. Over the entire four-year study period, the CCHT group had a lower death rate and longer survival time than the control group, while the control group had much higher frequency in all diabetes-related ambulatory care sensitive conditions such as lower-extremity amputations, uncontrolled diabetes, and bacterial pneumonia.
Date: October 1, 2009
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Blood Pressure Telemonitoring Feasible for Most Veterans
This article reports on the first six months of the Hypertension Intervention Nurse Telemedicine Study – an 18-month randomized clinical intervention to improve blood pressure (BP) control. Findings focus on the feasibility of using home BP telemonitoring devices to manage BP among Veterans. Technical alerts were generated if patients did not transmit their BP readings via the telemonitoring devices. Findings show that 75% of Veterans using the BP intervention were able to set up the telemonitoring devices and adhere to the study protocol. During the first six months of this study, 693 technical alerts were generated by 267 Veterans: 61% of the alerts were attributed to patient non-adherence, and 5% were attributed to a lack of patient knowledge (e.g., difficulty setting up the equipment, putting on the BP cuff). The authors suggest that despite the possibilities of improving health care using home BP telemonitoring equipment, there are groups who may require more support using this technology.
Date: September 1, 2009
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Teledermatology – Promising Technique for Improving Access to Care
In this study, teledermatology demonstrated good performance in comparison to clinic-based consultation for diagnostic agreement and diagnostic accuracy. Regarding diagnosis, teledermatologists agreed with each other and with clinic-based dermatologists at a rate comparable to group agreement among clinic dermatologists. Regarding accuracy, when compared to the gold standard of histology, rates ranged from 30% to 92% for clinic dermatologists and from 19% to 95% for teledermatologists.
Date: April 1, 2009
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In-Person Dermatology More Accurate than Teledermatology for Skin Lesions
Due to improved digital photography and Internet availability, at least two-thirds of teledermatology programs use store-and-forward technology – still images of skin viewed by remote dermatologists. This study compared the accuracy of store-and-forward teledermatology for non-pigmented skin lesions with in-person dermatology among 728 Veterans with a skin lesion diagnosed at one VA dermatology clinic. Findings show that the diagnostic accuracy of teledermatology was inferior to in-person dermatology, but the accuracy of treatment plans was equivalent. The addition of polarized light dermatoscopy (PLD) to macro images (standard method used in teledermatology) yielded significantly better diagnostic accuracy for teledermatology overall, but there remained no significant difference in the accuracy of treatment plans. Although the diagnostic accuracy of teledermatology was inferior to standard clinical dermatology, this study confirms the clinical utility of teledermatology for management of non-pigmented lesions and underscores the important role of PLD images for diagnosis of malignant non-pigmented lesions.
Date: April 1, 2009
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Psychotherapy Administered via Telephone Reduces Depression
Findings show a significant reduction in depressive symptoms for patients enrolled in telephone-administered psychotherapy as compared to those in control conditions (e.g. treatment as usual). Moreover, attrition rates were considerably lower than rates reported in face-to-face psychotherapy.
Date: September 1, 2008
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