Administrator and provider perceptions of the factors relating to programme effectiveness in implementing telemedicine to provide end-of-life care.

Two large hospice organizations in Kansas and Michigan began a telehospice project with the goal of improving care at the end of life using telemedicine. Hospice nurses provided services using video directly to the homes of hospice patients. The telemedicine equipment operated over ordinary telephone lines. Nursing services included symptom assessment and psychospiritual evaluations. Patients lived in both urban and rural settings. Studies were designed to evaluate utilization patterns, access to care, patient/carer acceptance, medical outcomes and cost. During the first year of the project, telehospice care was initiated at five rural sites (two in Michigan and three in Kansas) and three urban sites (two in Michigan and one in Kansas). There was greater telehospice activity in Michigan than in Kansas, with 118 and 44 patients served, respectively. The urban site in Kansas withdrew from the study after participating for only nine months. In an effort to understand the difference in utilization patterns and reasons for withdrawing from the project, in-depth interviews of key study participants, including hospice administrators, nurses and research personnel, were conducted. Human factors appear to be important in the adoption of novel telemedicine applications.

Telemedicine in Kansas: the successes and the challenges.

Based on our experience of telemedicine in Kansas, we have identified several key factors in the success of a telemedicine practice. Very early in any project, it is important to bring together all participants (especially the physicians who are expected to refer patients) to define the need, outline specific goals, analyse and test the technology, and develop a plan for the implementation. As with traditional health-care, many partners must come together, including primary-care practitioners willing to shoulder day-to-day responsibility for management of complex patients, nurses with special expertise and consultants willing to work with a remote team using telemedicine. These individuals must accept the challenges and appreciate the rewards of working in a different practice model, in which communication and interdependence are critical for success. The telemedicine consultant is only as good as the local health-care team. The technology itself is only a small part of the equation.

A cost measurement study for a home-based telehospice service.

A telehospice service is one in which telemedicine is used to provide hospice care in the home. To date, there have been few studies addressing the cost of home-based telemedical care, and none that specifically addresses cost-effectiveness for telehospice recipients. We measured costs for traditional hospice care as well as those associated with launching and operating a telehospice service. The costs were tallied over two separate three-month periods. For the first study period, costs were measured for traditional hospice home visits. During the second, expenses were monitored for traditional (in-person) and telehospice visits. For traditional care, the cost per visit was $126 and $141, for the first and secod time periods, respectively. The average telehospice visit cost was $29.

Patients' perceptions of a telemedicine specialty clinic.

We studied patients' perceptions of telemedicine (interactive video) as a means of delivering specialist oncology/haematology care. Semistructured telephone interviews were performed with 22 patients attending a tele-oncology/haematology clinic in Kansas. Interviews were audio-taped and thematic content analysis of the transcripts was done. The response rate was 96%. All participants expressed satisfaction with their tele-consultations. For 50% of respondents, satisfaction with the tele-oncology/haematology clinic was qualified by two factors: participants also saw the specialist in person on occasions and the clinic was perceived as providing mainly a 'monitoring' function. In addition, 9 of the 22 patients expressed concern about the role of the nurse as a proxy for the doctor in performing certain parts of the physical examination. Overall, participants valued improved access to specialist services but had clear views as to the limitations of such a service. As the use of telecommunications technology grows, patient perspectives merit greater attention.

An analysis of the suitability of home health visits for telemedicine.

To determine what percentage of traditional home health nursing visits could be done by telemedicine, we carried out a retrospective review of nursing charts (clinical records). Data of two types were recorded. The objective data, which were abstracted from the records, included demographic information, patient assessments, teaching activities and interventions. The subjective data were the opinions of four observers as to whether the visit could have been done using currently available telemedicine technology. Records were sampled randomly for patients who had received home nursing care from three home health agencies in rural and urban areas during the winter and summer of 1996. A 54-item coding instrument was applied to 906 different charted home nursing visits. For 412 (46%) of these, the on-site nursing could reasonably have been replaced by telenursing. Significant factors determining the possible use of telenursing included primary diagnosis, number of interventions and patient age. Among the 10 most common primary diagnoses, the most amenable to telenursing care were chronic airway obstruction and joint disorders; the least amenable were coagulation disorders and anaemia. Telenursing visits could substitute for a substantial fraction of on-site home nursing visits. This has important implications in terms of reducing the cost of home nursing care.

A cost measurement study for a tele-oncology practice.

The costs of providing oncology services in three different ways were measured. Services were provided to a peripheral hospital by: conventional clinics, in which the oncologist worked at the hospital concerned; outreach clinics, in which an oncologist was flown in periodically from a central hospital; telemedicine clinics, in which the oncologist at the central hospital practised via a video-link. During a one-year study period, 2400 patients were seen in conventional clinics, 81 in outreach clinics and 103 in telemedicine clinics. At these workloads the average costs per patient were $149, $897 and $812, respectively. However, the average costs cannot be compared directly without further information about the shape of the unit cost curves.

Hospice care using home-based telemedicine systems.

A pilot study of telenursing for terminally ill patients at home was launched as a collaborative effort between KUMC and the Kendallwood Hospice. The service used the public telephone network. Interactive video equipment was installed in the homes of three nurses who received after-hours calls and in the homes of six hospice patients living in either Kansas or Missouri. Data concerning the utilization patterns were gathered for two separate three-month periods. Patients and caregivers reported general satisfaction with the telehospice system. Both the nurses and social worker providers became comfortable about video-calls. Nurses conducted video-assessments to determine whether an 'in person' visit was necessary. This was particularly helpful for rural patients who were living a long way from the base station. In addition, Kendallwood serves an urban population and, in certain areas, night-time nursing visits raise safety concerns.

A cost analysis of a tele-oncology practice.

Costs were monitored for three different types of oncology practice: a telemedicine clinic and a fly-in outreach clinic, both held in rural areas, and a traditional clinic held in a city hospital. Total expenses were calculated over the year May 1995 to April 1996. The average cost per telemedicine visit was $812. The average cost per outreach clinic visit was $897. Flying in oncology support for this practice was therefore about 10% more costly than telemedicine. While the outreach cost may have been inappropriately high due to a slow start-up phase, it was still less expensive during this period to be seen via telemedicine. For comparison, the average cost per traditional oncology clinic visit was $149. However, this figure does not take into account the costs of access to a city-based service by rural patients.

Practising oncology via telemedicine.

Although there are increasing numbers of telemedicine programmes in the USA, few have offered teleoncology services, so that the role of telemedicine in the practice of clinical oncology has yet to be fully defined. Telemedicine has been used successfully for direct patient care in Kansas. It is also a method of providing supportive care for the cancer patient, including assessments of pain and nutrition. In addition, televised tumour conferences and nursing education courses can help smaller communities develop a level of expertise that allows patients to be treated locally. Telemedicine may well be used in future for access to national and international cancer experts, and for participation in new cancer treatment protocols through cooperative group trials. When practising oncology via telemedicine, there are unique problems, including issues regarding technology (interactive video and radiograph review) and practice (patient/oncologist preferences and doctor-patient communication). Very little has been published in the area of tele-oncology so far, and studies concerning its efficacy, cost-effectiveness and the best organizational structure are still in progress. However, telemedicine appears to be a useful technique in the practice of oncology.

Paraneoplastic pemphigus in a patient with non-Hodgkin's lymphoma.

Paraneoplastic pemphigus (PNP) is an autoimmune disorder occurring in the setting of an underlying neoplasm in which patients have polymorphous skin and mucous membrane lesions. We describe a patient with non-Hodgkin's lymphoma who developed bullous, ulcerating lesions in an area being treated with radiation therapy. The diagnosis of PNP was confirmed by indirect immunofluorescence of the patient's serum on rat bladder. The disorder was refractory to therapy, and ultimately the patient expired.

Adverse haematological complications of anticancer drugs. Clinical presentation, management and avoidance.

Haematological complications frequently occur in patients treated with chemotherapeutic agents. The degree and duration of bone marrow suppression depends upon the type of agent used. In general, agents that are cell cycle phase-specific tend to cause early myelosuppression with rapid marrow recovery, as compared to the non-phase-specific agents. Host factors including patient age, nutritional status, marrow infiltration or damage, and hepatic and renal function also affect haemotoxicity. Chemotherapeutic agents suppress proliferating or potentially proliferating precursors of neutrophils, platelets and red blood cells to the same extent. With most drugs, neutropenia tends to be dose limiting and more severe than thrombocytopenia. Because of the longer life span of red blood cells, severe anaemia is rarely a problem. The management of myelosuppression is multifaceted, and consists of aggressive antibiotic therapy to treat or prevent the infections that occur with neutropenia, as well as red blood cell and platelet transfusion support to correct anaemia and prevent bleeding. The role of the haemopoietic growth factors including erythropoietin, colony-stimulating factors and the interleukins is currently being evaluated in clinical trials. Haemolytic uraemic syndrome, haemolytic anaemia and therapy-induced myelodysplasia and/or acute leukaemia are uncommon and potentially severe complications of chemotherapeutic agents.

Therapy of aplastic anemia with sequential antithymocyte globulin and cyclosporin.

Five consecutive patients with severe aplastic anemia were treated with antithymocyte globulin followed by cyclosporin A. All received antithymocyte globulin initially, and because of lack of response within a 4 week period, cyclosporin was administered subsequently. Hematologic improvement occurred within four months of initiation of cyclosporin. Four patients no longer require blood product support, while one remains transfusion-dependent. In two patients, thrombocytopenia developed when the cyclosporin was tapered but re-institution of the drug resulted in a prompt improvement of counts. These observations indicate that the sequential use of antithymocyte globulin and cyclosporin may be an effective therapeutic approach in the treatment of severe aplastic anemia.

Methotrexate-associated, early-onset pancytopenia in rheumatoid arthritis.

A patient with rheumatoid arthritis presented with pancytopenia 3 weeks after initiation of low-dose methotrexate administered orally. She had minimal renal insufficiency and hypoalbuminemia prior to initiation of methotrexate therapy, and had received a nonsteroidal anti-inflammatory drug concurrently. Bone marrow recovery occurred within 3 weeks. Patients receiving low-dose methotrexate therapy for rheumatoid arthritis require early monitoring for bone marrow injury, especially those who have risk factors for possible methotrexate toxicity.

Malignancy-induced lactic acidosis.

Lactic acidosis, a rare and usually fatal complication of malignancy, is defined as a clinical condition in which the pH is less than or equal to 7.35 and the serum lactate level greater than or equal to 5 mEq/L. We have described the clinical aspects of four cases of lactic acidosis associated with malignancy, and have reviewed all reported cases of lactic acidosis in malignancy meeting the criteria. Rapid recognition of the condition and prompt institution of chemotherapy led to reversal of lactic acidosis in three of our four patients, but long-term survival is related to the responsiveness of the underlying tumor.