Telemedicine in the sleep laboratory: feasibility and economic advantages of polysomnograms transferred online.

The costs for polysomnography (PSG) and alternative diagnostic procedures for sleep-disordered breathing are challenging public health care systems. We wanted to determine if a telemedicine protocol with online transfer of PSGs from a remote site could be cost-effective and clinically useful while improving patient access to full PSG. Fifty-nine PSGs were performed in 54 pulmonary patients with suspected sleep-disordered breathing at a remote hospital. The data were transferred by File Transfer Protocol (FTP) via the Internet to Walter Reed Army Medical Center (WRAMC) for scoring and interpretation. The results were faxed back to the remote hospital. Clinical utility was assessed by evaluating the reasons for patient referral and the resulting diagnoses. The economic benefits were calculated by comparing direct expenses of the telemedicine protocol with costs for contracting PSGs at outside sleep laboratories. A total of 93% (55) of all PSGs were transferred successfully online. Of the 54 patients, 47 had PSGs performed for diagnosis (including three split-night studies), 8 underwent treatment titration, and 1 patient had both overnight studies. Diagnoses were obstructive sleep apnea in 43 patients, central sleep apnea in 2, and upper airway resistance syndrome in 2. The disease conditions were defined as severe in 27 patients, moderate in 12 patients, and mild in 8 patients. Each PSG cost $700 (including costs for lost transmissions) compared to $1,250 for referral to a private sleep laboratory. A savings of $550 per study was realized with the telemedicine protocol. The online transfer of PSGs from a remote site to a centralized sleep laboratory is technically feasible and clinically useful. Telemedicine offers an effective alternative for cost reduction in sleep medicine while improving patient access to specialized care in remote areas.

Hospitalizations for fungal infections after renal transplantation in the United States.

Fungal infections in renal transplant recipients have not been studied in a national population. Therefore, 33,420 renal transplant recipients in the United States Renal Data System from 1 July 1994 to 30 June 1997 were analyzed in a retrospective registry study of hospitalized fungal infections (FI). FI were most commonly associated with secondary diagnoses of esophagitis (68, 23.9%), pneumonia (57, 19.8%), meningitis (23, 7.6%), and urinary tract infection (29, 10.3%). Opportunistic organisms accounted for 95.4% of infections, led by candidiasis, aspergillosis, cryptococcosis, and zygomycosis. Most fungal infections (66%) had occurred by six months post-transplant, but only 22% by two months. In logistic regression analysis, end-stage renal disease due to diabetes, duration of pre-transplant dialysis, maintenance tacrolimus and allograft rejection were associated with FI. In Cox regression analysis, recipients with FI had a relative risk of mortality of 2.88 (95% CI=2.22-3.74) compared to all other recipients. Among FI, zygomycosis and aspergillosis were independently associated with both increased patient mortality and length of hospital stay. Most fungal infections in renal transplant recipients were opportunistic, occurred later than previously reported, and were associated with greatly decreased patient survival. Recipients with diabetes, prolonged pre-transplant dialysis, rejection, and tacrolimus immunosuppression should be considered high risk for FI.

Early experience using telemedicine for neonatal surgical consultations.

BACKGROUND/PURPOSE: Telemedicine affords the opportunity to extend the presence of surgical evaluation to centers without an on-site pediatric surgeon. However, concern for cost, accuracy of diagnosis, and physician acceptance have limited its use. METHODS: Using a low-cost, desktop computer-based system, this study was designed to test the effectiveness of telemedicine in neonatal surgical consultation. RESULTS: Early experience with six video-teleconference (VTC) and six store-and-forward consultations are presented. Diagnosis was established accurately in all cases. With the three intestinal cases (jejunal atresia, duplication cyst, and r/o malrotation), diagnostic studies were guided by the images transmitted with the consult. Earlier care could be implemented in other cases. Technical problems were encountered primarily with the VTC modality, which also proved more consuming of physician time. CONCLUSIONS: Telemedicine was used successfully in each case and proved accurate in diagnosis and guiding further evaluation. This is the first report of the use of telemedicine for surgical consultation in the intensive care nursery.

Performance improvement in telemedicine: the essential elements.

Performance improvement activities in telemedicine may be placed into five categories. (1) Licensing and credentialing. Telemedicine overcomes geographical boundaries, but its reach is constrained by state laws on licensing. Some states require a state license, whereas others grant "consultation exemptions" for out-of-state physicians. Simple renewable licenses do not guarantee quality. Potential solutions include a national telemedicine license or license reciprocity laws for telemedicine. (2) Data security and privacy. Telemedicine technology raises some security concerns. Differences in reporting requirements among states complicate the issue of privacy. Storage of telemedicine consultation records may help physicians document care decisions for risk management, but conventional long-term storage may not be feasible because of cost constraints and may not be required to document the encounter appropriately. (3) Informed consent. Potential failures in security and transmission are new, and should be communicated to the patient. (4) Peer review. Peer review findings encourage thorough, accurate, and legible documentation. Results should be recorded by provider and must be available during the recredentialing process. (5) Tailored performance improvement initiatives. By using established principles and techniques, performance improvement initiatives can gather, analyze, and communicate information about the cost-effectiveness of telemedicine. These performance improvement efforts are the heart of quality management and are critical to the justification of telemedicine. Walter Reed Telemedicine has put into effect a performance improvement plan in accordance with this outline. This article describes the plan and suggests it as a model for other telemedicine programs.

Utility of repeated fiberoptic bronchoscopy for suspected malignancy.

We retrospectively evaluated records of 1598 fiberoptic bronchoscopies (FBs) performed on 1,391 patients (PTs) between Jan 1, 1986 and Dec 31, 1990. We found a progressive increase from 11 percent to 20 percent in the use of repeated fiberoptic bronchoscopy (RFB). Of the 254 RFBs, 151 were done in PTs with known or suspected intrathoracic malignant neoplasms. The 78 (of 151) RFBs performed in PTs with previously diagnosed malignant neoplasms were used to guide additional therapy. The other major indication for RFB (67 of 151) was to evaluate new suspicious lesions that had not been diagnosed on the initial FB. RFB specimens were positive in 36, false-negative in 24, and true-negative in 7 PTs. For some PTs, RFB could probably have been avoided if at initial FB physicians had (1) used fluoroscopy to direct transbronchial lung biopsies in PTs expected to have normal airways, (2) performed transbronchial needle aspiration in all PTs with extraluminal disease or mediastinal adenopathy, and (3) obtained bronchial biopsy specimens from all PTs with endobronchial lesions. In PTs whose initial FB specimens were nondiagnostic despite visualization of endobronchial or extraluminal abnormalities, RFB was associated with a significant diagnostic yield and obviated the need for more morbid, surgical staging procedures.