Effectiveness of Telehealth in Rural and Remote Emergency Departments: Systematic Review.

BACKGROUND: Emergency telehealth has been used to improve access of patients residing in rural and remote areas to specialist care in the hope of mitigating the significant health disparities that they experience. Patient disposition decisions in rural and remote emergency departments (EDs) can be complex and largely dependent on the expertise and experience available at local (receiving-end) hospitals. Although there has been some synthesis of evidence of the effectiveness of emergency telehealth in clinical practice in rural and remote EDs for nonacute presentations, there has been limited evaluation of the influence of contextual factors such as clinical area and acuity of presentation on these findings. OBJECTIVE: The aims of this systematic review are to examine the outcome measures used in studying the effectiveness of telehealth in rural and remote EDs and to analyze the clinical context in which these outcome measures were used and interpreted. METHODS: The search strategy used Medical Subject Headings and equivalent lists of subject descriptors to find articles covering 4 key domains: telehealth or telemedicine, EDs, effectiveness, and rural and remote. Studies were selected using the Population, Intervention, Comparator, Outcomes of Interest, and Study Design framework. This search strategy was applied to MEDLINE (Ovid), Cochrane Library, Scopus, CINAHL, ProQuest, and EconLit, as well as the Centre for Reviews and Dissemination databases (eg, National Health Service Economic Evaluation Database) for the search period from January 1, 1990, to May 23, 2020. Qualitative synthesis was performed on the outcome measures used in the included studies, in particular the clinical contexts within which they were interpreted. RESULTS: A total of 21 full-text articles were included for qualitative analysis. Telehealth use in rural and remote EDs demonstrated effectiveness in achieving improved or equivalent clinical effectiveness, appropriate care processes, and-depending on the context-improvement in speed of care, as well as favorable service use patterns. The definition of effectiveness varied across the clinical areas and contexts of the studies, and different measures have been used to affirm the safety and clinical effectiveness of telehealth in rural and remote EDs. The acuity of patient presentation emerged as a dominant consideration in the interpretation of interlinking time-sensitive clinical effectiveness and patient disposition measures such as transfer and discharge rates, local hospital admission, length of stay, and ED length of stay. These, together with clinical area and acuity of presentation, are the outcome determination criteria that emerged from this review. CONCLUSIONS: Emergency telehealth studies typically use multiple outcome measures to determine the effectiveness of the services. The outcome determination criteria that emerged from this analysis are useful when defining the favorable direction for each outcome measure of interest. The findings of this review have implications for emergency telehealth service design and policies. TRIAL REGISTRATION: PROSPERO CRD42019145903; https://tinyurl.com/ndmkr8ry.

Effectiveness and cost-effectiveness of TeleStroke consultations to support the care of patients who had a stroke presenting to regional emergency departments in Western Australia: an economic evaluation case study protocol.

INTRODUCTION: The Western Australia (WA) Acute TeleStroke Programme commenced incrementally across regional WA during 2016-2017. Since the introduction of the TeleStroke Programme, there has been monitoring of service outputs, including regional patient access to tertiary stroke specialist advice and reperfusion treatment; however, the impact of consultation with a stroke specialist via telehealth (videoconferencing or telephone) on the effectiveness and cost-effectiveness of stroke care and the drivers of cost-effectiveness has not been systematically evaluated. METHODS AND ANALYSIS: The aim of the case study was to examine the impact of consultation with a stroke specialist via telehealth on the effectiveness and cost-effectiveness of stroke and transient ischaemic attack care using a mixed methods approach. A categorical decision tree model will be constructed in collaboration with clinicians and programme managers. A before and after comparison using state-wide administrative datasets will be used to run the base model. If sample size and statistical power permits, the cases and comparators will be matched by stroke type and presence of CT scan at the initial site of presentation, age category and presenting hospital. The drivers of cost-effectiveness will be explored through stakeholder interviews. Data from the qualitative analysis will be cross-referenced with trends emerging from the quantitative dataset and used to guide the factors to be involved in subgroup and sensitivity analysis. ETHICS AND DISSEMINATION: Ethics approval for this case study has been granted from the Western Australian Country Health Service Human Research and Ethics Committee (RGS3076). Reciprocal approval has been granted from Curtin University Human Research Ethics Office (HRE2019-0740). Findings will be disseminated publicly through conference presentation and peer-review publications. Interim findings will be released as internal reports to inform the service development.

Effectiveness and cost-effectiveness of telehealth in rural and remote emergency departments: a systematic review protocol.

BACKGROUND: Emergency telehealth has been used to improve accessibility of rural and remote patients to specialist care. Evidence to date has demonstrated effectiveness and cost-effectiveness of telehealth in rural and remote emergency departments within a variety of contexts. However, systematic reviews to date have not focused on the rural and remote emergency departments. The purpose of this study is to review the outcome measures used in evaluations of emergency telehealth in rural and remote settings and assess evidence relating to their effectiveness and cost-effectiveness. METHODS: Randomised controlled trials, non-randomised controlled trials, and full and partial economic evaluations (e.g. cost-effectiveness, cost-benefit, and cost-utility analyses) of telehealth in rural and remote emergency departments will be included. Comprehensive literature searches will be conducted in multiple electronic databases (from 1990 onwards): MEDLINE (Ovid), Cochrane Library, Scopus, CINAHL, ProQuest, EconLit, CRD databases (e.g. NHS Economic Evaluation database), and Tufts Cost-Effectiveness Registry. Two authors will independently screen all citations, full-text articles, and abstract data. The methodological quality (or risk of bias) of individual studies will be appraised using an appropriate tool. A systematic narrative synthesis will be provided with information presented in the text and tables to summarise and explain the characteristics and findings of the studies. If feasible, we will conduct random effects meta-analysis. DISCUSSION: This review will identify gaps in the current body of evidence relating to the effectiveness and cost-effectiveness of rural and remote emergency telehealth services. By confining to articles written in the English language, this analysis may be subjected to publication bias and results need to be interpreted accordingly. We believe the results of this review could be valuable for the design of future economic evaluations of emergency telehealth services implemented in the rural and remote context. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019145903.

Using the Healthy Community Assessment Tool: Applicability and Adaptation in the Midwest of Western Australia.

Population-based studies have associated poor living conditions with the persistent disparity in the health of Aboriginal and non-Aboriginal Australians. This project assesses the applicability of the Health Community Assessment Tool and its role in improving the environment of a small community in the Midwest of Western Australia (WA). The action research cycles started with the initial reflection on the suitability of the HCAT version 2 for the local community context and whether it was fit-for-purpose. The researcher provided 'critical companionship', while the participants of the study were invited to be co-researchers (the Assessors) who critically examined the HCAT and assess the community. The relevant domains to the serviced town (an outer regional community) were pest control and animal management; healthy housing; food supply; community vibrancy, pride and safety; reducing environmental tobacco smoke; and promoting physical activity. The Assessors found the HCAT descriptors mostly aligned with their community context but found some of the items difficult to apply. Based on participant's suggestions, some of the original scoring scales were reformatted. School attendance and illicit drug use were identified as a key outcome indicator for youth but were missing from the HCAT. The HCAT domains applied helped streamlining core business of agencies in the local community. The face validity of HCAT items were confirmed in this research with minor adjustments to reflect local context. Youth engagement to education is of high community concern and the development of an item would create similar interagency collaborative dialogues.

An exploration of inter-organisational partnership assessment tools in the context of Australian Aboriginal-mainstream partnerships: a scoping review of the literature.

BACKGROUND: The need for better partnerships between Aboriginal organisations and mainstream agencies demands attention on process and relational elements of these partnerships, and improving partnership functioning through transformative or iterative evaluation procedures. This paper presents the findings of a literature review which examines the usefulness of existing partnership tools to the Australian Aboriginal-mainstream partnership (AMP) context. METHODS: Three sets of best practice principles for successful AMP were selected based on authors' knowledge and experience. Items in each set of principles were separated into process and relational elements and used to guide the analysis of partnership assessment tools. The review and analysis of partnership assessment tools were conducted in three distinct but related parts. Part 1- identify and select reviews of partnership tools; part 2 - identify and select partnership self-assessment tool; part 3 - analysis of selected tools using AMP principles. RESULTS: The focus on relational and process elements in the partnership tools reviewed is consistent with the focus of Australian AMP principles by reconciliation advocates; however, historical context, lived experience, cultural context and approaches of Australian Aboriginal people represent key deficiencies in the tools reviewed. The overall assessment indicated that the New York Partnership Self-Assessment Tool and the VicHealth Partnership Analysis Tools reflect the greatest number of AMP principles followed by the Nuffield Partnership Assessment Tool. The New York PSAT has the strongest alignment with the relational elements while VicHealth and Nuffield tools showed greatest alignment with the process elements in the chosen AMP principles. CONCLUSIONS: Partnership tools offer opportunities for providing evidence based support to partnership development. The multiplicity of tools in existence and the reported uniqueness of each partnership, mean the development of a generic partnership analysis for AMP may not be a viable option for future effort.

mTOR controls cell cycle progression through its cell growth effectors S6K1 and 4E-BP1/eukaryotic translation initiation factor 4E.

The mammalian target of rapamycin (mTOR) integrates nutrient and mitogen signals to regulate cell growth (increased cell mass and cell size) and cell division. The immunosuppressive drug rapamycin inhibits cell cycle progression via inhibition of mTOR; however, the signaling pathways by which mTOR regulates cell cycle progression have remained poorly defined. Here we demonstrate that restoration of mTOR signaling (by using a rapamycin-resistant mutant of mTOR) rescues rapamycin-inhibited G(1)-phase progression, and restoration of signaling along the mTOR-dependent S6K1 or 4E-BP1/eukaryotic translation initiation factor 4E (eIF4E) pathways provides partial rescue. Furthermore, interfering RNA-mediated reduction of S6K1 expression or overexpression of mTOR-insensitive 4E-BP1 isoforms that block eIF4E activity inhibit G(1)-phase progression individually and additively. Thus, the activities of both the S6K1 and 4E-BP1/eIF4E pathways are required for and independently mediate mTOR-dependent G(1)-phase progression. In addition, overexpression of constitutively active mutants of S6K1 or wild-type eIF4E accelerates serum-stimulated G(1)-phase progression, and stable expression of wild-type S6K1 confers a proliferative advantage in low-serum-containing media, suggesting that the activity of each of these pathways is limiting for cell proliferation. These data demonstrate that, as for the regulation of cell growth and cell size, the S6K1 and 4E-BP1/eIF4E pathways each represent critical mediators of mTOR-dependent cell cycle control.

Mammalian cell size is controlled by mTOR and its downstream targets S6K1 and 4EBP1/eIF4E.

The coordinated action of cell cycle progression and cell growth (an increase in cell size and cell mass) is critical for sustained cellular proliferation, yet the biochemical signals that control cell growth are poorly defined, particularly in mammalian systems. We find that cell growth and cell cycle progression are separable processes in mammalian cells and that growth to appropriate cell size requires mTOR- and PI3K-dependent signals. Expression of a rapamycin-resistant mutant of mTOR rescues the reduced cell size phenotype induced by rapamycin in a kinase-dependent manner, showing the evolutionarily conserved role of mTOR in control of cell growth. Expression of S6K1 mutants that possess partial rapamycin-resistant activity or overexpression of eIF4E individually and additively partially rescues the rapamycin-induced decrease in cell size. In the absence of rapamycin, overexpression of S6K1 or eIF4E increases cell size, and, when coexpressed, they cooperate to increase cell size further. Expression of a phosphorylation site-defective mutant of 4EBP1 that constitutively binds the eIF4E-Cap complex to inhibit translation initiation reduces cell size and blocks eIF4E effects on cell size. These data show that mTOR signals downstream to at least two independent targets, S6K1 and 4EBP1/eIF4E, that function in translational control to regulate mammalian cell size.