What is the key message of your article?
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High levels of patient safety are demonstrated in this pediatric telemedicine service.
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Unique and specific measures are implemented by physicians working in this setting to promote patient safety.
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Analysis shows a positive correspondence between online-physician’s decisions and the “subsequent outcomes” (i.e., parents’ compliance with guidelines and the system’s performance following each consultation).
What does it add to the existing literature?
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Telemedicine and telephone triage may compromise patient safety, particularly if urgency is underestimated and especially with nurse-tele-triage.
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Previous researches on the safety and quality of tele-triage services have presented conflicting results.
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Unlike most previous studies, this research investigates the decision-making process of physicians, not nurses, in a pediatric telemedicine service.
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This analysis of patient safety in a pediatric tele-triage service incorporated several measures of the physicians’ decision-making process: diagnosis “appropriateness”; decision “reasonableness”; and the physicians’ subjective perspectives.
What is the impact?
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This study supports previous studies that found telephone triage to be safe for patients.
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The results demonstrate overall high safety of this pediatric telemedicine service with excellent diagnosis appropriateness and good decision reasonableness. In addition to high patient compliance, this service was found to help reduce the workload of GPs and EDs.
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Despite the overall high safety in this pediatric telemedicine-triage service, decision-makers must strive to find additional means for further improving diagnoses accuracy and optimal treatment decisions.
Background
Pediatric telemedicine service
The aim of the study
Methods
Section I
Primary (main) decision
Secondary (sub) decision
Diagnosis appropriateness
Decision reasonableness
Statistical analysis
Section II
Results
Section I
Medical and general characteristics
Range | Mean | Median | SD | Other | ||
---|---|---|---|---|---|---|
Patients | ||||||
Age (years) | 0.01–17.3 | 3.43 | 1.70 | 4.04 | – | |
Gender | – | – | – | – | Boys- 171 (50.4%); | Girls-168 (49.6%) |
Background | – | – | – | – | Healthy −92.3% | WB/Asthma- 4.2% |
Parents/ Family | Range | Mean | Median | SD | Other | |
Religion | Jewish-326 (96.2%) | Non-Jewish- 13 (3.8%) | ||||
Gender of Parent who Called | Mothers-267 (78.8%); | Fathers-65 (19.2%); | Both-5 (1.5%); | The child-1 (0.3%) | ||
Place of Residence | ||||||
Type | Small place (town, village, kibbutz)-119 (35.1%) | City-202 (59.6%) | Missing-18 (5.3%) | |||
Center/Periphery | Center-196 (57.8%), | Periphery, North-67 (19.8%) | Periphery, South-58 (17.1%) | Missing-18 (5.3%) | ||
Doctors | ||||||
Age (years) | 40–50: 78 (23%); 50–60: 127 (37.5%); > 60: 134 (39.5%) | |||||
Gender | Male- 240 (70.8%); | Female − 99 (29.2%) | ||||
Religion | Jewish- 222(65.5%); Muslim-86 (25.4%); Christian- 31 (9.1%) | |||||
Country of Birth | Israel-206 (60.8%); Not Israel-133 (39.2%) | |||||
Medical school | Israel-150 (44.2%); Not Israel-189 (55.78%) | |||||
Specialty type | General Pediatrics-298 (87.9%) | Sub-specialty-41 (12.1%) | ||||
Shift | Range | Mean | Median | SD | ||
Call duration (minutes) | 1.18–14.44 | 3.30 | 3.13 | 1.57 | ||
Time of Shift | Evening (20.00–24.00)-161 (47.5%) | Night (24.00–06.00)-54 (15.9%); | Day (06.00–20.00)-114 (33.6%) | |||
Day of Shift | Weekday-165 (48.7%) | Friday-57(16.8%) | Sabbath/holiday-117(34.5%) | |||
Conversation type | Phone-330 (97.3%) | Video- 6 (1.8%) | Phone & Photos- 3 (0.9%) | |||
Medical Factors | ||||||
Background diseasesa | No disease-313 (92.3%) | Wheezing Bronchitis/ Asthma −14 (4.12%) | ||||
Duration of disease | Several minutes-10 (2.9%) | Several hours (< 24)-208 (61.4%) | Several days- 121 (35.6%) | |||
Severity of disease | Mild-134 (39.5%) | Moderate-190 (56%) | Severe-15 (4.4%) | |||
Previous doctor’s visit | Yes-77 (22.7%) | No-262 (77.3%) | ||||
Times called service | 1 time-332 (97.9%) | 2 times −7 (2.1%) | ||||
Length of conversation (min) | Range:1.18–14.54 | Mean: 3.30 | Median:3.13 | |||
Correspondence to protocols | Yes-321 (94.7%) | No-18 (5.3%) |
Dependent variables
Variable | Description | |||
---|---|---|---|---|
Primary Decision (n = 339) | 1. Referred to the ED: 96 consultations (28.3%) | 2. Not referred to the ED: 243 consultations (71.7%) | ||
Secondary Decisionb (n = 243) | 1. Wait & see: – Observe the child and visit the community physician the following day: 181 (74.5%) consultations. | 2. Active decisions:e Intervention: 30 (12.5%) consultations (such as sending a digital prescription to the parents.) Further inquiry: 32 (13%) consultations (using a video, sending photos, visiting the community medical service, arranging an additional conversation, or providing a referral to the ED in case symptoms worsen.) | ||
Diagnosis Appropriateness | 1. In 334 (98.5%) of the cases, the diagnoses were considered appropriate by the two reviewer doctors. | 2. In 5 (1.5%) of the cases, the diagnoses were considered inappropriate by the two reviewing doctors. | ||
Decision Reasonableness | First stagec | In 310 of the consultations, the physicians’ decisions were considered reasonable by the two reviewer doctors. | In 17 consultations, the two reviewer doctors agreed that the decisions were unreasonable. | In only 12 cases, one reviewer deemed the decision unreasonable, but the other did not. |
Second staged | In 312 (92%) of the consultations, the physicians’ decisions were considered reasonable by the two reviewer doctors. | In 27 (8%) of the consultations, the physicians’ decisions were considered unreasonable by the two reviewer doctors. |
Diagnosis appropriateness
Decision reasonableness
Reasonable Decision * ED referral Cross tabulation | |||
---|---|---|---|
ED referral | Total | ||
Yes | No | ||
Reasonable Decision | |||
Yes | |||
Count | 87 [TP] | 225 [TN] | 312 |
% within Reasonable Decision | 27.9% | 72.1% | 100.0% |
% within ED referral | 90.6% | 92.6% | 92.0% |
No | |||
Count | 9 [FP] | 18 [FN] | 27 |
% within Reasonable Decision | 33.3% | 66.7% | 100.0% |
% within ED referral | 9.4% | 7.4% | 8.0% |
Total | |||
Count | 96 | 243 | 339 |
% within Reasonable Decision | 28.3% | 71.7% | 100.0% |
% within ED referral | 100.0% | 100.0% | 100.0% |
Should have been referred to ED | Should not have been referred to ED | |
---|---|---|
ED Referral, Yes (by the online physician) | 87 TP | 9 FP |
ED Referral, No (by the online physician) | 18 FN | 225 TN |
Effect of medical factors on the dependent variables
Effect of non-medical factors on dependent variables
Telemedicine Physician’s Primary Decision | Subsequent Outcomesa | ||||
---|---|---|---|---|---|
The patient was not referred to the ED | Visited a physician within the next 2 days | Did not visit a physician within the next 2 days | Visited the ED despite having no referral | ||
231b [~ 71.5%] | 122 [~ 37.7%] Not referred to the ED | 104 [~ 32.2%] | 4 [~ 1.2%] | ||
1 [~ 0.3%] Referred to ED by the face-to-face physician (and released) | |||||
The patient was referred to the ED | Visited the ED and was discharged | Visited the ED and was admitted | Did not visit the ED despite a referral … | ||
29 [8.9%] | |||||
but visited a physician in the community | and did not visit physician in the community | ||||
92 [~ 28.4%] | 51 [~ 15.7%] | 12 [~ 3.7%] | 14 [~ 4.3%] | 15 [~ 4.6%] | |
Total | 323 [100%] | ||||
Missing | 16 |
- The vast majority of parents accepted the physicians’ recommendations and did not go to the ED at their own initiative; approximately half (n = 123; 52%) went to their community doctor for a follow-up within 2 days of the online consultation. Only one patient was referred by the community physician to the ED and was eventually discharged – suggesting that the online physician had made a good clinical decision.
- Of all the patients who contacted the online service, 45% (n = 104) did not need to go to the community clinic for treatment (implying that the treatment or advice they received from the online physician was helpful).
- Only 1.7% (4 cases) went to the ED at their own initiative, without a referral from the online physician. (In such cases, patients are required to pay for the visit themselves as this cost is not covered by their medical insurance through the MCO.) All four were discharged.
- Of all the children referred to the ED, 68% (n = 63) actually visited the ED and were examined there.
- Of all those referred to the ED, 55% (n = 51) were released after being examined.
- Of all those referred to the ED, 13% (n = 12) were hospitalized.
- Of all those referred to the ED, 31% (n = 29) did not go to the ED. Approximately half of them (n = 14; ~ 15%) preferred going to the community physician over the next 2 days following the online consultation. The remainder (n = 15; ~ 15%) did not visit the ED and did not visit their community physician.
- Even when considering the assumption that those who did not visit the ED despite being referred showed clinical improvement (allowing them to wait for the community physician or not going for a follow up at all), the overall TP value was high (68%).
Section II
Main Characteristics of Physicians | |
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Gender | Males-9, Females-6 |
Age (years) | Age groups: 40–50: 6; 50–60: 7; > 60: 2 |
Range: 42–67; Mean: 52.33; Median: 53 | |
Religion | Jewish: 11; Christian: 1;Muslim: 3 |
Place of birth | Israel: 11; Not Israel: 4 (Ukraine-1, Russia-1, USA-1, Argentine-1) |
Place of medical studies | Israel: 10; Not Israel: 5 (Italy-2, Russia-1, Argentine-1, Ukraine-1) |
Major place of work | Community: 11; Hospital: 4 |
Specialty (general vs. specialized) | General pediatricians: 8; Specialized pediatricians: 7 |
Experience as Pediatrician (years) | Range: 4–30; Mean: 19.13; Median: 18.46 |
Experience in Telemedicine (years) | Range: 0.5–9; Mean: 4.76; Median: 5 |
Active in Pediatric telemedicine | Yes: 11; No: 3; Other:1 (also active in other telemedicine service) |
..."I feel relatively confident and made professional decisions."