In a large-scale randomised controlled trial, researchers from the UK and Sweden have shown that internet-mediated cognitive behavioural therapy (CBT) can provide results for post-traumatic stress disorder (PTSD) that are in line with conventional face-to-face care. The article, which was recently published in Lancet Psychiatry, also shows that the time required for therapists is greatly reduced, which could mean that more patients can be treated and have access to the right help.
Common symptoms include reliving the trauma, overexcitement, avoidance and emotional and cognitive consequences, such as depression and difficulty concentrating. Psychological treatment in the form of CBT has been shown to have good effects in PTSD, but access to care is limited and varies between different places.
Post-traumatic stress disorder (PTSD) is a psychiatric diagnosis that affects about 5-10% of the population. PTSD occurs as a result of experiencing – or witnessing – severe, life-threatening and traumatic events, such as abuse, war, accidents and mistreatment.
The study recruited 217 participants through the NHS or self-referral. Mean age was 36·36 years, with a range 18–71 years; 158 (73%) self-reported as female, 57 (26%) as male, and two (1%) as other. Of these, 52 (24%) participants met self-reported criteria for ICD-11 complex PTSD. The advantages in outcome for internet-mediated therapy were greater for participants with high dissociation or complex PTSD symptoms, and mediation analyses showed both treatments worked by changing negative meanings of the trauma, unhelpful coping, and flashback memories. No serious adverse events were reported.
Ghanaian health tech startup mPharma is building a network of community pharmacies across Africa as it plans to be the go-to primary healthcare service provider for millions of people. Drug supply in Africa is often unaffordable and counterfeits are rife.
The startup’s community (Mutti) pharmacies are essentially mini-hospitals offering affordable services, ranging from medical consultation to diagnostic and telehealth services.
The company plans more Mutti pharmacies to extend its reach ater raising $35 million, bringing the total amount raised by mPharma to $65 million.
According to mPharma co-founder and CEO Gregory Rockson told TechCrunch, the new financing will be used to ramp up its infrastructure, staff and expansion into African markets.
“We are hiring over 100 engineers to build all our technology in-house and this includes a massive data infrastructure we are creating. We are also investing in other skilled talent like doctors and nurses, professionals that are critical in the work we do,” Rockson told TechCrunch.
Originally founded in 2013, mPharma aims to manage prescription drug inventory for pharmacies and their suppliers, retail pharmacy operations and to provide market intelligence to hospitals, pharmacies and patients.
In October 2021, the startup added telehealth services to its portfolio, catching the telemedicine wave brought in by the COVID pandemic. Rockson told TechCrunch the startup was planning to have 100 virtual centres after six months. The number of virtual centres is primed to grow further alongside mPharma’s plan to increase its community pharmacies from 200 to over 2000 in three years.
Patients in Ghana, Nigeria, Kenya, Zambia, Malawi, Rwanda and Ethiopia, where mPharma has a presence, can access these virtual services. Startups like mPharma aim to address healthcare gaps in Africa.
Sub-Saharan African countries have an average of 0.23 doctors for every 10 000 people against the best ratio of 84.2 doctors in some of the most developed countries. In addition, healthcare infrastructure remains critically underdeveloped.
“COVID showed us that the best form of care is local, it is in the community, and the closest thing in communities are pharmacies. We believe that the pharmacy of the future, which is what we are creating, is one built around longitudinal care not episodic care,” said Rockson.
“We are transforming community pharmacies into the foundation of a modern health system in Africa. We will have a Mutti pharmacy in every community on the continent, guarantee the availability and safety of medicines for each community and utilise the physical infrastructure of Mutti pharmacies to expand Mutti Doctor (the telemedicine service), creating the largest network of doctor offices and diagnostic centres.”
During the early days of the COVID pandemic, an automated text messaging system saved two lives a week, and, overall, the patients who enrolled in that system had a 68% lower mortality rate than those not on it.
These insights about Penn Medicine’s COVID Watch – a system designed to monitor COVID outpatients using automated texts and then escalate those with concerning conditions to a small team of health care providers – were published in the Annals of Internal Medicine.
“At the beginning of the pandemic, we instinctually thought patients needed extra support at home, even if they weren’t sick enough or ill yet. And if they were to get very sick, we wanted to help them get to the emergency department earlier, so COVID Watch was our solution,” said a co-primary investigator of the study, Krisda Chaiyachati, MD, the medical director of Penn Medicine OnDemand and an assistant professor of Medicine. “Our evaluation found that a small team of five or six nurses staffing the program during some of the most hectic days of the pandemic directly saved a life every three to four days.”
COVID Watch was rapidly developed and designed to help patients with the virus recover safely at home and keep hospital capacity available. The system uses algorithmically guided text message conversations with patients to assess their conditions. It sent out twice-daily routine questions to patients, such as “How are you feeling compared to 12 hours ago?” and “Is it harder than usual for you to breathe?” If a patient indicated a worsening condition, follow-up questions were asked and they were elevated to the human members of a centralised team – headed by co-author Nancy Mannion, DNP, COVID Watch’s nurse manager – who would call to check in and recommend hospitalisation, if needed.
Since the start of COVID Watch, nearly 20 000 patients have been enrolled in it.
“We did an early analysis of the system and determined that we could safely monitor more than 1,000 patients simultaneously, 24/7, with a small, well-trained team of registered nurses,” said Anna Morgan, MD, COVID Watch’s medical director and an assistant professor of Internal Medicine. “On top of that, those same nurses could often also take care of other COVID-related tasks such as helping patients arrange COVID testing and discussing their results, which is important during surges.”
To further assess COVID Watch’s effect on patients, researchers analysed data from every adult who received outpatient care from Penn Medicine, starting the day COVID Watch launched until Nov. 30, 2020. Only three out of 3448 patients in COVID Watch died within 30 days of their enrollment, compared to 12 of the 4337 otherwise equivalent patients outside of the program: a three times higher mortality rate. At 60 days after enrollment, five people within COVID Watch died compared to 16 not using the system.
This amounted to a 68 percent reduction mortality risk with COVID Watch. Additionally, COVID Watch was credited with saving 1.8 lives per 1000 patients at 30 days, and 2.5 per 1000 at 60 days.
The study’s lead author and co-primary investigator, M. Kit Delgado, MD, an assistant professor of Emergency Medicine and Epidemiology, believes that the benefits seen by COVID Watch patients could be explained by: Increased access to and use of telemedicine, and more frequent and earlier trips to the hospital – an average of two days earlier for COVID Watch patients – when symptoms worsened.
Importantly, the study found that COVID Watch was equally accessible and effective for everyone.
“We saw a higher proportion of higher-risk patients and also low-income and Black patients enrolled in COVID Watch, but the fact that we measured a significant benefit associated with enrollment in the program is a good indicator that there truly is a treatment benefit for everyone,” Prof Delgado said. “It’s crucial that we found all major racial and ethnic groups benefited because non-white and low-income communities have had disproportionately higher infection rates, lower access to care, and higher death rates. This implies that this model of care could have reduced disparities in COVID outcomes if it was scaled up more broadly to these communities.”
The COVID Watch team plans to see if the approach, which had originally been built off a system for keeping tabs on chronic obstructive pulmonary disease (COPD) patients, can be applied to helping people with other conditions manage their health at home. They see the system as a lasting technology that will play an important part in future care.
Researchers reviewing patient surveys before and during the COVID pandemic found that nearly half preferred telemedicine and that general patient satisfaction scores were equally high for both video conferencing and office visits.
The study, published in the Journal of the National Comprehensive Cancer Network, assessed patient satisfaction and preferences for telemedicine. It found that 45% of people with cancer preferred telemedicine, while 34% preferred office visits, and 21% had no preference.
The researchers reviewed survey responses from 1077 radiation oncology patients across seven centres, with questionnaires based on office and telemedicine visits between December 2019 and June 2020. In terms of patient satisfaction, most reported either no difference or improvement with telemedicine overall (91%) compared to office visits, with similar results for their confidence in their physician (90%), understanding their treatment plans (88%), and confidence their cancer will be treated appropriately (87%).
Co-lead author Narek Shaverdian, MD, MSK Department of Radiation Oncology said: “These findings provide some evidence that there is a role for telemedicine beyond the COVID-19 pandemic and that it can be a particularly useful tool for certain patients – especially those who may have challenges coming on-site for an appointment. Giving patients flexibility and options by being able to see them both in-person and through telemedicine can improve access to care.”
Notably, two-thirds of respondents considered telemedicine to be a superior option when it came to treatment-related costs, such as travel and lost wages.
Co-lead author Erin F. Gillespie, MD, MSK Department of Radiation Oncology said, “An individual visit to the physician’s office can be costly—including transportation, parking, and time off from other activities. Telemedicine takes away most of this cost and inconvenience, and could therefore reduce the overall burden of engaging with the healthcare system. Also, the ability for family and friends to join the conversation from any location can be game-changing.”
The researchers found patient responses varied significantly between video conferencing versus audio. Patients who had telephone-only appointments were more likely to say they thought they would benefit more from an in-person visit.
“Telemedicine can be a resource to increase access to care, but only if patients have and can use these video capabilities,” said Dr. Shaverdian. “There is so much that you learn just by seeing a patient and using visual cues to guide a discussion. A voice-only encounter with a patient you’ve never met before is challenging.”
“Digital tools like telemedicine have the unfortunate potential consequence of paradoxically increasing disparities in access to care,” noted Dr. Gillespie. “But the counter to that is there will be some disadvantaged patients that would not have accessed the system at all, either due to technologic barriers or travel time, and now can connect at least by phone, which is an important and positive change.”
A small survey has found that although therapists appear to prefer virtual sessions over in-person meetings, a significant proportion admit to being distracted while delivering care.
A third of respondents admitted to providing lower-quality care to clients during online sessions. Overall, 39% admitted to checking emails and social media while providing virtual care.
These were the results of a survey of 600 therapists conducted and published by OnlineTherapy.com, a virtual directory for teletherapists and counselors. It’s also an affiliate of the controversial app BetterHelp, stating on their website that the company “may receive compensation from BetterHelp if you purchase products or services through the links provided.”
Online care is generally well received by therapists: nearly half said they prefer virtual sessions over in-person meetings. They appreciated many advantages of virtual therapy, such as working from home which allows therapists to keep a flexible schedule and increases their availability. Video sessions also provide therapists with a uniquely intimate look into their clients’ daily lives, making assessing their mental health easier.
However, teletherapy has introduced its own challenges. Besides the struggle to remain for therapists to stay focused themselves, 56% of those surveyed said their clients are more easily distracted during virtual sessions, and 48% reported technological issues as a major impediment to their practice.
Peter Yellowlees, MD, of UC Davis Health in Sacramento, California, noted with concern and confusion that 16% of therapists reported substance use before or during their sessions.
“There are all sorts of people in this world who call themselves therapists, most of whom have very reasonable training, but quite a number don’t,” Dr Yellowlees told MedPage Today, expressing serious doubts about whether these rates of social media distraction and substance use during virtual sessions would ring true for mental health clinicians with PhDs and MDs.
According to a spokesperson from OnlineTherapy.com, the survey only asked if respondents were currently practicing mental health professionals and did not ask for their credentials or certifications.
The results of the survey did, however, echo Dr Yellowlees’s own concerns of mental health problems on the rise of among therapists in general. The vast majority (90%) said that during the last year they suffered mental health issues, including anxiety disorders (50%) and depressive disorder (48%). This would likely impact the level of care that a therapist able to provide to their clients.
A further concern is that 17% of respondents reported seriously considered suicide since the start of the pandemic.
But Dr Yellowlees also sees teletherapy as a way for therapists to start getting the help that they need, rather than simply treating themselves in fear of stigma or possible repercussions for their licences.
“It’s undoubtedly helped significantly,” Dr Yellowlees said. “We know that certain teletherapies are actually good for the mental health of providers, as well as the patients.”
Following arthroscopic knee surgery, patients are as satisfied with telemedicine follow-ups as they are with in-person follow-up, according to a new study published in The Journal of Bone & Joint Surgery.
“Patient satisfaction with overall care is equivalent between telemedicine and office-based follow-up after an arthroscopic meniscal surgical procedure in the immediate postoperative period,” wrote Christina P Herrero, MD, and colleagues of NYU Langone Health.
The study recruited 122 patients who underwent arthroscopic surgery on the meniscus in the knee, which is one of the most common orthopaedic surgical procedures. Of these patients, 88% had a removal of the meniscus (meniscectomy), with the rest undergoing meniscal repair procedures. Patients were randomly assigned to either office-based or telemedicine follow-up, scheduled for 5 to 14 days postoperatively. During both types of follow-up visits, the surgeon spoke to the patient about the surgical findings, pain the patient might be experiencing, and the postoperative recovery period, as well as performing a physical examination that included range-of-motion testing.
The telemedicine follow-ups were performed using the patient’s home computer or mobile device via a telemedicine program that was compliant with privacy rules. Surgeons of course were unable to physically feel or touch the knee during telemedicine follow-ups. However they could still conduct a visual assessment of wound healing, drainage, and swelling.
Overall satisfaction ratings were nearly identical between groups. The surveys showed average patient satisfaction scores (on a 0-to-10 scale) were 9.77 in office-based follow-up and 9.79 for telemedicine follow-up. In both groups, only about 20% of patients said they would have preferred the other type of visit. There was also similar improvement observed in pain scores between groups: from about 5 (out of a maximum of 10) on the day of the surgery to 3 at the follow-up visit.
Telemedicine has become all the more crucial in the COVID pandemic to minimise contact, but the levels of satisfaction shown indicate that it may be a promising standard mode of care in the future, especially for cases where access to physical follow-up consultation may be difficult for the patients.
“Telemedicine may be a reasonable alternative to office-based follow-up after knee arthroscopy,” Dr Herrero and coauthors concluded. “[Our] study only evaluated the first postoperative visit, but future studies may benefit from expanding the use of telemedicine to longer-term follow-ups or to additional surgical procedures.”
Journal information: Herrero, C. P., et al. (2021) Patient Satisfaction Is Equivalent Using Telemedicine Versus Office-Based Follow-up After Arthroscopic Meniscal Surgery. The Journal of Bone & Joint Surgery. doi.org/10.2106/JBJS.20.01413.
A study in Cleveland, USA, showed that at hospitals without 24/7 on-site intensivists, those that had intensivists available to deliver telemedicine had lower ICU mortality rates.
“In an ideal world, patients would have an intensivist at the bedside 24/7, but the reality is that even if we had all of the money in the world, we don’t have enough trained professionals to do the job,” Udeh said.
Out of patients treated at one of nine hospitals within the Cleveland Clinic Health System, patients receiving ICU telemedicine were 18% less likely to die and were discharged 2 days sooner than patients who received traditional ICU care, without 24/7 on-site intensivist care.
The unadjusted 30-day mortality among the telemedicine patients was 5.5%, while in the standard care group it was significantly higher at 6.9%.ICU length of stay was significantly shorter in the ICU telemedicine group, as was the length of total hospital stay.
Udeh said that an intensivist monitoring patients via telemedicine has access to relevant data and can perform the same functions as an on-site clinician, short of physical contact. Intensivists can monitor multiple patients and have two-way communication with bedside nurses. Dedicated software is available, including tools to identify deteriorating patients needing care.
Speaking to MedPage Today, Udeh said ICU telemedicine offers an intermediate treatment strategy between large academic centres with 24/7 on-site intensivist care, and smaller hospitals without such care. More research is needed to understand how telemedicine leads to reduced mortality, he added.
“If I had to speculate I would imagine this would probably be due to patients’ receiving more timely needed interventions,” he said.
“We think these findings provide further reassurance about the value of ICU telemedicine, particularly in light of our collective experience in 2020,” said Udeh. “With the COVID-19 pandemic, telemedicine in general assumed greater prominence.”
CU telemedicine can benefit both large hospital systems and smaller, individual hospitals, he said.
“Smaller hospitals may have no intensivist at all or they may have only one,” he said. He added that, according to one recent survey, about half of US hospitals do not have an intensivist on staff.
ICU telemedicine still has considerable expenses associated with it, however; at $50 000 per bed in first year costs, it may be hard to justify for resource-constrained hospitals.
Presentation information: Udeh CI, et al “ICU telemedicine and clinical risks associated with 30-day mortality: a retrospective cohort study” SCCM2021.
A pair of reports suggests that modern communication methods may be appropriate for post-surgery recovery, albeit at the risk of exacerbating the downsides of any language barriers and digital literacy.
In the midst of the COVID pandemic, telemedicine uptake and use has been greatly expanded by health care providers. In one small trial, cut short by COVID, researchers investigated whether telemedicine was an adequate form of patient follow-up after low-risk surgery.
The video-based post-discharge visits were as effective in terms of getting patients to return to the hospital within 30 days for a hospital encounter. The video visits were half an hour shorter but provided patients with the same amount of time with their surgeons.
However, out of 1645 individuals screened, many participants were excluded due to language difficulties, and 50 were excluded due to a “technology barrier”.
Caroline Reinke, MD, MSHP, of Carolinas Medical Center in Charlotte, North Carolina, and her team wrote, “Patients and clinicians should be reassured that the critical visit portion, time together discussing medical needs, is preserved. This information will help surgeons and patients feel more confident in using video-based virtual visits.”
Reinke and her team noted that COVID cut the study short: “Although we did not reach target enrollment, noninferiority was demonstrated for postdischarge virtual visits in our study sample and was further supported via a simulation model.”
In another study, Marie-Laure Cittanova, MD, PhD, of Clinique Saint Jean de Dieu in Paris, and her team compared using SMS to contact patients as opposed to calling them. When contacted after being told to expect a contact throughout the following day, 46.2% of patients were reachable by phone, compared to 85.3% by SMS.
Patients expressed similar levels of satisfaction with the SMS service, which was significantly cheaper than using phone calls. However, the single-centre study lacked generalisability.
Journal information (primary source): Harkey K, et al “Postdischarge virtual visits for low-risk surgeries: a randomized noninferiority clinical trial” JAMA Surg 2021; DOI: 10.1001/jamasurg.2020.6265.
Journal information (secondary source): Cittanova M, et al “Association of automated text messaging with patient response rate after same-day surgery” JAMA Surg 2021; DOI: 10.1001/jamanetworkopen.2020.33312.
