Journal of the Asian Medical Students Association
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Prehospital Telemedicine: The Solution to Reduce Treatment Delays and Mortality in ST-Elevation Myocardial Infarction and Acute Ischemic Stroke
Get PDFIntroduction (Aims and Problem Statement):
ST-elevation myocardial infarction (STEMI) and acute ischemic stroke (AIS) reperfusion treatment are critically time-dependent. The longer time to reperfusion strongly correlates with higher mortality and adverse outcomes.
In developing countries, common causes of the delay in prehospital care are the lack of professional prehospital healthcare providers and collaboration among organizations. Moreover, hospitals capable of providing reperfusion treatment are limited.
Telemedicine has facilitated the reach of specialists for remote triage and diagnosis in prehospital settings.
This white paper aims to examine the efficacy of telemedicine in reducing treatment delays and mortality and to propose strategies and policies to implement telemedicine in prehospital care for STEMI/ AIS management.
Method:
A search of MEDLINE, EMBASE, PubMed, and Scopus was performed, and studies will be systematically reviewed by two reviewers; if consensus is required, a third reviewer will be consulted.
Findings:
Out of 446 reviewed articles, 64 met the criteria and were critically analyzed; 36 and 28 studies focused on STEMI and AIS, respectively.
Overall, the reviewed studies suggested that implementing telemedicine in prehospital care efficiently reduced time to reperfusion and lower mortality.
The common limitation in developing countries is the absence of efficient technological and medical devices in ambulances.
Proposed Solutions:
The following solutions are suggested:
Devise the STEMI/ AIS network and facilitate the implementation of telemedicine to collaborate between pre-hospital healthcare providers and on-call specialists; therefore, remote diagnosis and triage are efficiently performed, then patients are transported to the prealerted potential hospital for immediate definitive treatment.
The ambulances should be well-equipped with reliable 12-lead Electrocardiogram, high-resolution video camera, and stable network connection that enable effective telemedicine practice, with minimum delays.
Pre-hospital health care providers should be trained to proficiently work in novel telemedicine implemented pre-hospital care.
Conclusion:
Implementing pre-hospital telemedicine with well-equipped ambulances can reduce time to reperfusion, mortality rate, and adverse complication in STEMI/ AIS.
Keywords: ST-elevation myocardial infarction; Acute ischemic stroke; Telemedicine; Treatment delay; Prehospital care; Emergency medicin
Breaking Through Barriers on Improving Balance and Gait in Parkinson's Disease: A Systematic Review and Meta-Analysis of Virtual Reality Telerehabilitation
Get PDFIntroduction: Parkinson's disease (PD) is the most common neurodegenerative and movement disorder globally with prevalence increasing 155.50% in the last 20 years. While being proven beneficial, early rehabilitation has been unoptimized during the Covid-19 pandemic. Virtual reality (VR) telerehabilitation as a novel approach has been shown to be as effective as face-to-face treatment, yet there have been no systematic reviews and meta-analyses specifically assessing its efficacy in improving PD patients’ balance and gait.
Objective: To investigate the efficacy of VR telerehabilitation for improving motor function, specifically balance and gait, in PD patients.
Method: A systematic review was performed based on PRISMA guideline and the literature search was conducted in PubMed, Cochrane Library, Science Direct, EBSCOHost, ProQuest, Wiley Library, and Google Scholar based on our inclusion and exclusion criteria. A meta-analysis was conducted using RevMan 5.4 to compute the summary of mean difference (MD) and 95% confidence intervals (CI) for the Berg Balance Scale (BBS) outcome.
Result: Nine randomized controlled trials (RCTs) with a total of 467 participants were included and evaluated for risk of bias. The pre- and post- VR intervention forest plot of BBS score depicts a significant effect without heterogeneity (MD: -4.29; 95% CI: -5.90−-2.68; p<0.00001; I2= 0.00). In terms of control and intervention efficacy, the forest plot of BBS score also depicts a significant effect (MD: 2.31; 95% CI: 0.41−4.21; p=0.02; I2= 0.23). The overall gait function was found to be significantly better in the VR group compared to the control group.
Conclusion: PD patients with VR telerehabilitation significantly had better improvement in balance and gait. Therefore, VR can be a preferential choice of rehabilitation for PD patients, especially during this Covid-19 pandemic. However, further large-scale RCTs are still needed to ensure the applicability of VR telerehabilitation.
Keywords: virtual reality, VR, telerehabilitation, balance, gait, parkinson’s diseas
Analysis of Necessary Legal and Regulatory Amendments to Permanently Legalize Telemedicine in South Korea
Get PDFAnalysis of necessary legal and regulatory amendments to permanently legalize telemedicine in South Korea.Introduction –Telemedicine remained illegal in South Korea until covid 19 struck Korea. However, in response to covid-19 many temporary policies have been introduced to permit telemedicine, which minimizes doctor-patient contact. Now, the Korean parliament is gradually attempting to reform medical laws to permanently legalize telemedicine in South Korea. To successfully implement telemedicine in Korea, we realized the need to identify a few legal and regulatory issues that must be adjusted before permanently legalizing telemedicine. Objective – The objective of this study is to identify legal and regulatory issues that can arise from legalization of telemedicine and to suggest legislative changes that are needed. Method: A specific literature search was conducted on DBpia, Korea Law Information Center, and google scholars using the following keywords: Telehealth, regulations, legal issues, South Korea, USA, Japan, Sweden. The search was set to garner articles or legal cases published from 2012 to 2022. We evaluated multiple articles on telemedicine regulation and related laws in Korea. Also, we compared Korean medical service act with telemedicine laws in countries that have partially or fully legalized telemedicine: USA, Japan, and Sweden.Result:1) Korea’s National Health Insurance must reform its insurance policy to cover telemedicine2) NHIS(National Health Insurance Service) should adequately price telemedicine and adequately set the reimbursement rate on telemedicine to encourage doctors to perform telemedicine3) Discussion is required to regulate groups or individual’s degree of access to medical treatment information and patient’s health information.4) The convenience of telehealth may result in overuse of medical resources. Thus, policies are necessary to prevent overuse of telehealth.5) Discussion on legalizing medication delivery is required.Conclusion:To successfully implement telemedicine in South Korea, legislative amendment is necessary on patient information protection act and medical service act. Furthermore, NHIS must undergo major reforms to allow reimbursement of telehealth
Improving Blood Glucose Management Through DiaBuddy: A Gamified Telehealth-based Application for Children With Type 1 Diabetes Mellitus
Get PDFIntroduction: Nearly 3% of all children around the world are currently suffering type 1 Diabetes Mellitus (T1DM), making it the leading cause of disability among children. Nevertheless, more than 73% of them fail to achieve recommended blood glucose levels. This situation calls for an urgent need to find a breakthrough solution in assisting children with T1DM to improve their quality of life.
Methods: We conducted a comprehensive literature evaluation followed by a mixed-method study design.
Findings: The challenges of performing T1DM self-management tasks among children patients are classified into lack of knowledge regarding low blood glucose, failure of adherence to self-care activities due to pain and inconvenience, and feeling alone and different from their peers which resulted in psychosocial difficulties and poor glucose control.
Proposed solutions: Therefore, we are proposing a gamified telehealth-based application for children with T1DM called DiaBuddy which can help increase their diabetes self-care adherence, assist in blood glucose monitoring and provide alerts and help when needed, provide educational information, and minimize the mental health challenges of T1DM care through the use of gamification. DiaBuddy will offer various features includine: a social online game where users can socialize with other T1DM children to prevent loneliness and also provide an incentive to perform diabetes self-care through customizable virtual pets (DiaTown); a dashboard for daily self-care tasks such as glucose monitoring and insulin administration schedules, logbooks, and reminders (DiaToday); interactive gamified educational content on T1DM management (DiaGames); and diet and exercise goals and challenges (DiaChallenge).
Conclusion: We believe that DiaBuddy can serve as a comprehensive solution in improving T1DM self management adherence, educate children on T1DM care, and provide relevant mental health support to children with T1DM. We hope that DiaBuddy can assist in enhancing the lives of children with T1DM all over the world
Efficacy and Acceptability of Telecounseling for Smoking Cessation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
Get PDFIntroduction: It remains unclear whether telemedicine is justified for smoking cessation in clinical application.
Objective: This systematic review and meta-analysis aimed to compare smoking cessation and dropout rates between telecounseling (TC) provided by health professionals and control interventions in active smokers.
Methods: The inclusion criteria were randomized controlled trials (RCTs) of TC in healthy and unhealthy smokers. If TC alone provided to the experimental groups, the control groups would receive no intervention or health education. If TC was an add-on, the control groups would receive the same care programs as the experimental groups, except for TC. The primary outcome was the smoking cessation rates during 1-4 months (short-term) and > 4 months (long-term) determined by 7 to 30-day smoking abstinence. Dropout rates were the secondary outcome. PubMed, EMBASE, and CINAHL were searched on April 20, 2022. The revised tool for assessing the risk of bias in randomized trials (RoB2) was utilized. The cessation rates were compared and pooled between groups using risk ratios (RRs) based on a random-effects model.
Results: Of 192 records retrieved from database searches, this meta-analysis included 7 RCTs (N = 3,939) of TC in active smokers. Participants in 5 of 7 RCTs were general people. Five and 2 RCTs were conducted in adults only and a mixed group of adolescents and adults, respectively. While 5 RCTs provided TC add-on, the other 2 RCTs gave TC alone. The most common type of TC was telephone counseling. TC group had significantly higher cessation rates both in short- (5 RCTs, RR = 3.32, 95% CI = 2.54-4.33, I2 = 15%) and long-term outcomes (4 RCTs, RR = 1.49, 95% CI = 1.11-1.99, I2 = 64%). Dropout rates were not significantly different.
Conclusion: Limited evidence suggests that TC is well accepted and potentially effective. TC should be utilized in smoking cessation programs.
Keywords: Smoking cessation, telemedicine, video counseling, quitline, nicotine dependence, randomized control trial, meta-analysis, systematic revie
Effectiveness of Digital Handwashing Intervention as a Breakthrough to Control COVID-19 and Transmissible Disease Outbreaks: A Meta-Analysis of Clinical Trials
Get PDFIntroduction: The unprepared global health community is severely impacted by COVID-19 pandemic, which increases the urgency of reducing disease transmission. Handwashing is a protective behaviour, but its practice is insufficient with current methods. Digital intervention is potentially efficient in promoting better handwashing not only in COVID-19 but also in other diseases.
Objective: This review is aimed to explore the effectiveness of digital handwashing interventions for transmissible diseases.
Method: Following PRISMA, we searched PubMed, Scopus, MEDLINE, Cochrane, EBSCOHost, Scopus, and Google Scholar, for clinical trials assessing handwashing behaviour change utilizing digital intervention from inception up to November 2021. Critical appraisal was performed using Cochrane Risk of Bias Tool 2.0 and converted to AHRQ standards. We utilised inverse variance, random effects model for quantitative synthesis.
Results: Four studies were included in this study. A significant handwashing frequency pooled mean difference (MD) of 0.71 [95%CI: 0.41-1.01, P<0.00001] towards the intervention group was obtained from this meta-analysis. The subgroup analysis done reported highest influence of digital intervention in frequency of handwashing before eating snacks (MD 1.04 [95%CI: 1.01-1.07]), after sneezing or coughing (MD 0.97 [95%CI: 0.85-1.08]), and after being close to ill person (MD 0.90 [95%CI: 0.97-0.93]). All of the results were found significant (P<0.0001) and homogenous (I2 <40%), except for handwashing after coming into the house subgroup. Another parameter, theory of planned behaviour (TPB), which may influence behavioural changes also gave a significant mean difference of 0.90 [95%CI: 0.54-1.27, P<0.0001]. In addition, notable MDs were obtained in attitude changes of participants (MD 2.01 [95%CI: 0.86-3.15, P=0.0006] and subjective norms (MD 0.57 [95%CI: 0.35-0.79, P<0.00001]) components.
Conclusion: Digital intervention significantly improves handwashing in terms of both frequency and planned behaviour, which leads to better transmission control. We recommend the possible widespread application of this intervention in facing the current pandemic and future outbreaks
A Cross-Sectional Survey on Telemental Health: What Do Service Providers and Clients Think of Its Effectiveness?
Get PDFIntroduction: While increasing evidence demonstrates equivalent effectiveness between telemedicine and direct patient care, little research has been done specifically on telemental health (TMH). TMH is the virtual delivery of healthcare and the exchange of healthcare information to provide mental health services to clients. This study focused on the perceptions of service providers (psychiatrists, psychologists and other mental health workers) and clients receiving care.
Objectives:
To establish the effectiveness of TMH as compared to direct patient care.
To identify confounding factors affecting the effectiveness of TMH.
To compare perceptions and barriers to TMH.
Method: Two sets of self-administered surveys were distributed to identified TMH service providers and clients using snowball sampling. Participation was voluntary, anonymous and de-identified. Five-point Likert scales were used to assess perceptions across domains of usefulness, effectiveness, ease of use, interaction quality, reliability and overall satisfaction, with safety being an additional domain for service providers. Information on barriers was also collected. Descriptive and inferential statistical analyses were conducted using Qualtrics software.
Results: TMH significantly improved access to mental health care. Among 37 service providers (SP) and 49 clients (CL) (n=86), more CL than SP favoured TMH. Most participants agreed that TMH is useful (SP 68.5%, CL 83.7%), effective (SP 59.9%, CL 74.9%), easy to use (SP 65.5%, CL 85.0%), satisfactory (SP 63.1%, CL 78.6%) and were willing to use TMH again (SP 78.4%, CL 75.5%). An unsuitable environment to carry out the session was a major barrier faced by most clients (39.2%). The survey uncovered several confounding factors that may have contributed to the perceived effectiveness of TMH.
Conclusion: Service providers and clients have different views on the effectiveness of TMH. While TMH may not be comparable to direct patient care, TMH services were met with high levels of satisfaction. TMH could, therefore, be considered as a supplement to mental health management
Mobile-Based Telemedicine as a Milestone for Lifestyle Monitoring Non-Alcoholic Fatty Liver Disease Patients: A Systematic Review and Meta-Analysis
Get PDFIntroduction:
NAFLD is the most common liver disease worldwide which can progress to fibrosis, cirrhosis, liver failure, hepatocellular carcinoma, and death. Currently, there is no therapeutic treatment and non-adherence to lifestyle modifications still possess problems. Diet and exercise are the main treatment for patients with NAFLD. Mobile-based telemedicine provides a powerful approach to dealing with behavioral changes.
Objective:
The study aims to assess the efficacy of mobile-based telemedicine in improving liver function and body weight among NAFLD patients.
Method:
The literature search was performed using PubMed, Plos One, Proquest, EBSCO Essentials, Wiley, and Cochrane using the keyword: Non-alcoholic fatty liver disease, smartphone, and telemedicine. The data was screened based on inclusion and exclusion criteria. Risk of bias assessment was done using ROB 2.0 tool. Meta-analysis was done using Review Manager 4.1 to measure the mean difference of AST, ALT, and weight improvement.
Results:
Five randomized controlled trials with a 513 total number of participants were included. Overall study considered as low risk of bias. The meta-analysis showed AST, ALT and weight improvement with MD -9.68 (random effect; 95 % CI -16.48 to -2.88; P = 0.005), MD -19.72 (random effect; 95 % CI -32.26 to -7.18; P = 0.002), and MD -2.34 (fixed effect; 95% CI -3.52 to -1.15; P = 0.0001) respectively.Conclusion:
Mobile-based telemedicine has been proved to significantly improve liver function by reducing AST and ALT levels and body weight in NAFLD patients
Preparedness of Diabetic Patients for Receiving Telemedical Healthcare: A Cross-Sectional Study
Get PDFIntroduction
The advent of telemedicine comes with certain technological requirements the availability, accessibility & affordability of which might prove to be a hurdle in employing tele-medical solutions for day-to-day care.
Objective
To understand the feasibility of telemedicine among diabetic patients by assessing Knowledge, Attitude and Practice towards diabetes management & Tele-preparedness of Diabetic patients.
Method
Patients aged >18 years participating in Free Diabetes Screening Camps, either previously diagnosed with diabetes or undiagnosed with a random blood sugar level of more than 200 mg/dL were interviewed regarding their Knowledge, Attitude, Practice and Preparedness for Telemedicine.
Result
Among n=223 (females 52.01%, mean age 57.21±13.68 years) patients, only 11.65% knew the normal blood glucose range, 73.09% were taking oral hypoglycemics & 15.69% were on Insulin Therapy. 67.26% considered taking their medicine very important. 15.24% had physical limitations (08.52% in walking, 02.69%% in hearing & 01.79% in vision) that affected their ability to perform self-care. 58.74% were having comorbidities out of which Hypertension (30.49%), was the most prevalent. When assessed for self-care behavior 49.32% participated in regular exercise (walking, jogging & yoga, being the most common) and 41.25% agreed that physical exercise is very important for diabetes. In terms of Tele-preparedness, 64.57% were technically equipped and capable of independently operating video conferencing applications. 51.56% of the population had Glucometers in their homes, out of which only 46.95% (n=54) were able to use Glucometers themselves.
Conclusion
While most of the study population were aware of the importance of regular monitoring for Diabetes and practiced self-care behavior, challenges like lack of technical resources and their utilization still remain a limitation and need to be tackled for strengthening the care of such patients through Telemedicine
A Qualitative Systematic Literature Review of Patient and Service Provider Barriers in Implementing Diagnostic Teledermatology: Implications for Policy
Get PDFIntroduction: Both synchronous and ‘store-and-forward’ teledermatology has risen significantly in the COVID-19 pandemic, enabling clinicians to remotely triage and diagnose multiple conditions without hindrance. Its utilization has increased by over 700% during the first wave of the pandemic in the US. In the UK, evidence of a nationwide triage-model suggested modest cost-savings and conservation of in-person appointment slots, while maintaining high diagnostic concordance and patient satisfaction. However, multiple roadblocks still exist in embracing teledermatology worldwide.
Objective: To evaluate the barriers faced by patients and service providers in diagnostic teledermatology, while proposing policy recommendations to overcome these barriers.
Methodology: Studies from 2020-2022 meeting the inclusion criteria were sourced from databases MEDLINE and EMBASE, generating 575 abstracts. COVIDENCE was used to perform single-member abstract and full-text screening, generating 23 studies for data extraction which were compiled onto a spreadsheet. Thematic analysis was undertaken following Braun & Clarke’s model. Identified themes were evaluated and categorized into a framework of barriers faced by patients and service providers.
Results: Based on the thematic analysis, our framework identified 2 main themes to the barriers which patients and service providers faced respectively. Patient themes are: 1) incongruent patient beliefs and outcome expectancies, and 2) technological inaccessibility. Themes of barriers to service providers include 1) low confidence in clinicians’ own capabilities; and 2) failure of administration, coordination and strategy.
Conclusion: This qualitative analysis identified the most important barriers to patients and service providers. Universally, patients lack insight into the added value of a teledermatology service, preventing engagement. In developed countries, the most important concern was privacy, while in developing countries, the main issue was language barriers with technological interfaces. For service providers, the main concerns are legal regulation uncertainty and lack of training preventing uptake of teledermatology. We have proposed policy recommendations to mitigate and address these barriers