Minimally invasive fetal therapy for hydropic lung masses: three different approaches and review of the literature.

OBJECTIVE: To report three different antenatal therapeutic approaches for fetal lung masses associated with hydrops. METHODS: Three prospectively followed cases are described, and all 30 previously published minimally invasive cases of fetal therapy for hydropic lung masses are reviewed. RESULTS: Three hydropic fetuses with large intrathoracic lung masses presented at 17, 25 and 21 weeks of gestation, respectively. An aortic feeding vessel was identified in each case and thus a bronchopulmonary sequestration (BPS) was suspected. Under ultrasound guidance, the feeding vessel was successfully occluded with interstitial laser (Case 1), radiofrequency ablation (RFA) (Case 2) and thrombogenic coil embolization (Case 3). Complete (Cases 1 and 2) or partial (Case 3) resolution of the lung mass and hydrops was observed. A healthy infant was born at term after laser therapy (Case 1), and the involved lung lobe was resected on day 2 of postnatal life. In Case 2, hydrops resolved completely following RFA, but an iatrogenic congenital diaphragmatic hernia and abdominal wall defect became apparent 4 weeks later. The neonate died from sepsis following spontaneous preterm labor at 33 weeks. In Case 3, despite technical success in complete vascular occlusion with coils, a stillbirth ensued 2 days after embolization. CONCLUSIONS: The prognosis of large microcystic or echogenic fetal chest masses associated with hydrops is dismal. This has prompted attempts at treatment by open fetal surgery, with mixed results, high risk of premature labor and consequences for future pregnancies. We have demonstrated the possibility of improved outcome following ultrasound-guided laser ablation of the systemic arterial supply. Despite technical success, RFA and coil embolization led to procedure-related complications and need further evaluation.

Lest formalisms impede insight and success: evaluation in health informatics--a case study.

OBJECTIVES: To illustrate the advantages of an open-ended formative evaluation approach using a project-specific selection of methods over the controlled trial approach in the evaluation of health information systems. To illustrate factors leading to success and others impeding it in a telehealth project. METHODS: The methods and results of an evaluation of the BC Telehealth Program are summarized. RESULTS: The evaluation gave a comprehensive picture of the project, including assessment of the effects of an array of telehealth applications, and their economic impact. Factors leading to success and others preventing it are identified from the level of overall program management to the project specifics. The results include unanticipated effects and explanations for their reasons of occurrence. Neither the comprehensiveness of information nor the timeliness was achieved in a related project using a controlled trial approach. CONCLUSIONS: Not all types of health information system projects can be evaluated using the controlled trial approach. This approach may impede important insights. It is also usually much less efficient. Funding agencies and journal editors have to take this into account when selecting projects for funding and submissions for publication.

Success factors for telehealth--a case study.

PURPOSE: To present the lessons learned from an evaluation of a comprehensive telehealth project regarding success factors and evaluation methodology for such projects. METHODS: A recent experience with the evaluation of new telehealth services in BC, Canada, is summarized. Two domains of clinical applications, as well as educational and administrative uses, and the project environment were evaluated. In order to contribute to the success of the project, the evaluation included formative and summative approaches employing qualitative and quantitative methods with data collection from telehealth events, participants and existing databases. The evaluation had to be carried out under severe budgetary and time constraints. We therefore deliberately chose a broad ranging exploratory approach within a framework provided, and generated questions to be answered on the basis of initial observations and participant driven interviews with progressively more focused and detailed data gathering, including perusal of a variety of existing data sources. A unique feature was an economic evaluation using static simulation models. RESULTS: The evaluation yielded rich and detailed data, which were able to explain a number of unanticipated findings. One clinical application domain was cancelled after 6 months, the other continues. The factors contributing to success include: Focus on chronic conditions which require visual information for proper management. Involvement of established teams in regular scheduled visits or in sessions scheduled well in advance. Problems arose with: Ad hoc applications, in particular under emergency conditions. Applications that disregard established referral patterns. Applications that support only part of a unit's services. The latter leads to the service mismatch dilemma (SMMD) with the end result that even those e-health services provided are not used. The problems encountered were compounded by issues arising from the manner in which the telehealth services had been introduced, in particular the lack of time for preparation and establishment of routine use. Educational applications had significant clinical benefits. Administrative applications generated savings which exceeded the substantial capital investment and made educational and clinical applications available at variable cost. CONCLUSION: Evaluation under severe constraints can yield rich information. The identified success factors, including provision of an overarching architecture and infrastructure, strong program management, thorough needs analysis and detailing applications to match the identified needs should improve the sustainability of e-health projects. Insights gained: Existing assumptions before the study was conducted: Evaluation has to proceed from identified questions according to a rigorous experimental design. Emergency and trauma services in remote regions can and should be supported via telehealth based on video-conferencing. Educational applications of telehealth directed at providers are beneficial for recruitment and retention of providers in remote areas. Insights gained by the study: An exploratory approach to evaluation using a multiplicity of methods can yield rich and detailed information even under severe constraints. Ad hoc and emergency clinical applications of telehealth can present problems unless they are based on thorough, detailed analyses of environment and need, conform to established practice patterns and rely on established trusting collaborative relationships. Less difficult applications should be introduced before attempting to support use under emergency conditions. Educational applications are of interest beyond the provider community to patients, family and community members, and have clinical value. In large, sparsely populated areas with difficult travel conditions administrative applications by themselves generate savings that compensate for the substantial capital investment for telehealth required for clinical applications.

Video conferencing-based telehealth--its implications for health promotion and health care.

PURPOSE: To review the experience with a province-wide telehealth system in Canada, and its implications for health care and health promotion. To explore whether group support systems (GSS) based on networked computers can substitute for video conferencing technology. METHODS: Key results of the evaluation of the BC Telehealth Program are summarized. The potential of extending the successful principles through use of GSS is explored based on literature review, demonstrations, and trial use for educational applications. RESULTS: The BC Telehealth Program was designed to support health professionals at secondary care facilities, such as regional and district hospitals in two application domains: children's and women's health (C&W) and emergency room and trauma care (ER-Trauma). Successful applications extended beyond health professionals and focused on chronic conditions, the management of which is contingent on visual information, and involves established teams in regular scheduled visits or in sessions scheduled well in advance. Ad hoc applications, in particular applications under emergency conditions proved problematic. Administrative applications in support of telehealth implementation, e.g., through facilitation of management and provider education, are essential for clinical success. Savings from support of administrative applications exceeded the substantial capital investment and made educational and clinical applications available at variable cost. Educational applications were shown to have significant clinical benefits. Exploration of GSS technology showed that it may not be mature enough to substitute for video conferencing technology in support of sophisticated training and education aiming at clinical impact. CONCLUSION: The substantial clinical and efficiency gains provided by video conferencing-based telehealth may for now continue to depend on mature video-conferencing technology.