Methods
Patient demographics
The general profiles of patients managed by the QSCIS were obtained from the database records maintained by the SPOT. Permission to analyse the data was provided by the clinical service directors. All records were anonymised for patient confidentiality. Referral information included age, gender, cause of injury, type of injury, and place of residence (postcode).
Service utilisation
A retrospective audit of ambulatory care services provided by the QSCIS during a 6 year period (January 2008 – December 2013) was carried out. SPOT and health service database records were used with the permission of the health service to describe ambulatory services delivered through the Spinal Injuries Unit (SIU) Outpatient Clinics and the Spinal Outreach Team (SPOT). Activity, attendance and referral data was obtained from the central hospital outpatient activity data collection provided by the Metro South Hospital and Health Service and a database managed by SPOT. Activity included specialist consultations provided through the SIU Clinics and SPOT services (telephone support, home visits and outreach visits). Videoconference activity during this period was also reported.
A SPOT occasion of service was defined as any clinical activity that is attributable to a specific patient and is recorded as an occasion of service on the SPOT database and documented in clinical notes. A SPOT occasion of service involved an intervention with a patient, their significant others and service providers, either alone or in combination.
Place of residence
For all patients who attended an appointment at the SIU clinic or through SPOT, we categorised according to distance from Brisbane. The number of kilometres between place of residence and Brisbane was calculated using postcode and Google Maps. Comparisons were made between patients seen at the SIU clinic and those who received a SPOT service.
Original database reports were prepared for analysis using Microsoft Excel. Records were checked for duplicates and typographical errors. This study was approved by the Metro South Hospital and Health Service, through a formal service level agreement which includes service planning, development and evaluation.
Discussion
The QSCIS strives to provide a high quality, equitable service to people with SCI who live in disparate regions of a diverse and geographically vast state. However, anecdotally it is understood that the further away people live, the more logistically difficult it is to access specialist services for follow-up, therefore increasing the potential for inequity of access. The service broadens its reach to patients by offering a range of services in the form of outpatient clinics in Brisbane, outreach visits in regional towns, home visits and telephone support.
This study demonstrated that ambulatory services are provided to patients all throughout Queensland, and that about one third of all patients known to the service live further than 200 km away from Brisbane. Only about 10 % of all attendances at the SIU Outpatient Clinic involved people living further than 200kms from Brisbane. Outreach services provided by SPOT did support a larger proportion (33 %) of patients living further away from Brisbane, mainly by telephone contact, liaison with other health professionals or during physical outreach visits to regional centres.
The number of patients who did not attend (DNA) their appointment at the SIU Outpatient clinic was reported to be 17 %. Whilst one of the most common reported reasons for non-attendance is that patients forget about their appointment, we also suspect the logistical challenges of travelling to Brisbane, costs and availability of (carer) support may also be contributing factors [
7]. Non-attendance causes inefficiencies in the health system, and extends the amount of time patients have to wait for an appointment [
10].
The QSCIS currently uses a number of methods (with services provided by the SIU and SPOT) to attempt to address inequities caused for people who live at greater distances from the specialist SCI services in Brisbane. Current methods employed to improve the provision of follow-up services and assistance to people in regional, rural and remote centres consist primarily of written and telephone liaison with the individuals themselves, their general practitioners and other local community health and rehabilitation teams. A significant amount of time is also spent engaging with health care providers including rehabilitation medicine and other specialists at other local hospitals where people with SCI are being managed. There is an extensive Urology Database used to assist in managing the annual renal surveillance program in which people with SCI all over the state are sent reminder letters regarding the need to have renal imaging performed. People who live in regional, rural and remote areas have this performed by a local radiology service and the images are reviewed by the SIU Rehabilitation Physicians and Urologist at a weekly Urology Meeting.
More recently (March 2014), formal pre-booked telephone consultations have been introduced. Videoconferencing and face-to-face consultation by SIU medical specialists to distant sites have also occasionally been used but historically this has not been commonplace.
Apart from the SIU OPD, much of the responsibility for provision of ongoing and life-long management and rehabilitation for people with SCI falls to the Spinal Outreach Team. Specialist SCI medical support has traditionally been provided by medical staff from the SIU although more recently (February 2014), dedicated medical staffing for SPOT has also been trialled, in the form of a rehabilitation medicine trainee based in the community SCI teams.
To improve access to specialty SCI services, SPOT utilises a variety of service delivery methods including outreach visits to regional centres and extensive use of telephone and email communication with people with SCI and their local service providers. Videoconferencing is used extensively for training and education of other health professionals and providers.
Despite wide ranging and intensive activity by SPOT, including outreach, telephone, email and use of videoconferencing for education and training activities, this study indicates that the uptake of videoconferencing for clinical assessment and management purposes has not become a commonplace aspect of SPOT activity. The precise explanation for this is unknown but may relate to the extensive and clinically effective use of other telehealth methodologies (email and telephone) in combination with outreach visits, a philosophical preference to provide face-to-face consultation when possible and the historical lack of easy access to videoconferencing facilities for patients at the distant sites. Irrespective of the explanation, the study confirms both a relatively limited use of videoconferencing for clinical purposes in the SIU Outpatient Clinic and SPOT and an important opportunity for future service development in this area.
Research in this area of telehealth and SCI has revealed mixed results. Della Mea (2012) described the use of a web-based specialist support network established for follow up but found that uptake was very low amongst patients and feedback indicated that they felt more comfortable communicating with their GP by telephone [
11]. Conversely, a randomised controlled trial by Dallolio et al. compared one group of patients who received standard care whilst the second group received standard care and telemedicine [
8]. The study reported much higher satisfaction from the group who had access to telemedicine support. In another study, patients with spinal cord injury (new admissions) were exposed to an intervention upon discharge which involved videoconferencing support, telephone-based support or standard care and found that those supported by videoconference required the least number of hospital admissions [
12].
Considering people with spinal cord injury are likely to experience secondary complications following discharge from an acute setting, regular follow up with specialist rehabilitation services and primary care providers such as general practitioners is considered very important. Several studies reported the use of telehealth to prevent, diagnose or treat patients with spinal cord injury with pressure ulcers [
13‐
15]. In one study, videoconferencing was used on a weekly basis to connect patients at home, to monitor and to assess any potential complications. The study by Galea et al. described high satisfaction amongst both patients and caregivers; and a reduced rate of hospitalisations and overall length of stay [
16].
A clinical efficacy study of store and forward telehealth, where digital images were used to assess pressure ulcers at a distance was reported by Sarhan et al. [
17]. In this study, images were sent to nurses to assess the stage and location of pressure ulcers. Nurses reported high satisfaction associated with the quality of the images collected through this service. Overall agreement regarding the stage and location of pressure ulcers was around 85 %, which showed that a telehealth was a viable means of assessing patients at risk of pressure ulcers [
17]. When comparing conventional (face-to-face) assessments, Hill et al. also reported very high agreement for clinical decisions made with the use of digital images for patients with pressure ulcers [
18].
Although there is relatively little in the current literature regarding the use of telehealth for people with SCI, it does seem that there are relevant applications which would support and enhance the already extensive services provided by the QSCIS and would be highly beneficial, particularly for people living outside Brisbane and for those requiring regular review.
Limitations
A limitation of the study was our reliance on multiple databases with differing levels of detail pertaining to their respective services. The choice of outcome measures was dependent on the data available. In regards to the substantial number of occasions of service reported by SPOT in the form of telephone consultations, we were unable to differentiate between occasions of service involving direct client care versus liaison with other service providers.
Opportunities
There are three potential key areas where telehealth expansion within the QSCIS may be of benefit. The first is; the substitution of current face-to-face medical outpatient appointments with video consultations. This would not only save the patient the need to travel to Brisbane but could be done in partnership with general practitioners and other clinicians in the local community which would encourage better engagement with primary care providers and enhance continuity of care. The second area for telehealth expansion is with increased use of multi-disciplinary SPOT clinical videoconferences which involve SIU medical specialist input as well as SPOT allied health and nursing staff and the third is with SIU medical specialist involvement, by videoconference as part of SPOT outreach visits. In this situation, it is likely that the use of videoconferencing could enhance outreach capabilities, might save some clinicians the need to travel during an outreach visit but also allow a broader range of medical, nursing and allied health practitioners to participate in each outreach visit.
Another possibility is that videoconferencing could provide access to specialist services provided by SIU and SPOT in a more “on demand” manner, outside of the fixed outreach visit schedule and outpatient appointments but this could have significant implications on workforce and resources for both services.
Competing interests
The authors have no competing interests to declare.
Authors’ contributions
AS, KL and EV conceptualised the study and developed the methodology. EV carried out the data analysis with the support of AS, KL, TG, SH and KP. Expert advice relevant to the specialist field was provided by KP, SH, TG and SA. All authors contributed to the interpretation of results and the draft of the manuscript. AS, KP, TG and KL revised the manuscript. All authors read and approved the final manuscript.