key: cord-0259386-axrs9q62
authors: Buyting, R.; Melville, S.; Chatur, H.; White, C. W.; Legare, J.-F.; Lutchmedial, S.; Brunt, K. R.
title: Virtual care with digital technologies for rural and remote Canadians living with cardiovascular disease
date: 2020-12-19
journal: nan
DOI: 10.1101/2020.12.17.20248333
sha: f13164cbb0d6eb437d9fc82c8667a076b36f50f7
doc_id: 259386
cord_uid: axrs9q62

Canada is a wealthy nation with a geographically diverse population, seeking health innovations to better serve patients in accordance with the Canada Health Act. In this country, population and geography converge with social determinants, policy, procurement regulations, and technological advances, in order to achieve equity in the management and distribution of healthcare. Rural and remote patients are a vulnerable population; when managing chronic conditions such as cardiovascular disease, there is inequity when it comes to accessing specialist physicians at the recommended frequency-increasing the likelihood of poor health outcomes. Ensuring equitable care for this population is an unrealized priority of several provincial and federal government mandates. Virtual care technology may provide practical, economical, and innovative solutions to remedy this discrepancy. Here we review the literature pertaining to the use of virtual care technologies to monitor patients with cardiovascular disease living in rural areas of Canada. A search strategy was developed to identify the literature specific to this context across three bibliographic databases. 166 unique citations were ultimately assessed for eligibility, of which 36 met the inclusion criteria. In our assessment of these articles, we provide a summary of the interventions studied, their reported effectiveness in reducing adverse events and mortality, the challenges to implementation, and the receptivity of these technologies amongst patients, providers and policy makers. Further, we glean insight into the barriers and opportunities to ensure equitable care for rural patients and conclude that there is an ongoing need for clinical trials assessing virtual care technologies in this context.

Based on its geographic size and distributed population density, Canada is justified to become a 30 leader of innovation for remote medical care-whether the nation is optimally capitalizing on 31 this is unclear. Rural populations are essential to the well-being of a nation, as they are 32 naturalized environmental stewards; farmers and harvesters providing the majority of food, and 33 other natural resources that enable urban living and a trade economy. In contrast to urban 34 populations, rural patients are a vulnerable group in need of special attention to ensure equitable 35 healthcare delivery. [1] [2] [3] The inequities impacting rural populations are complex, but a major 36 concern is timely access to specialist physicians in accordance with clinical guideline 37

recommendations. 4-6 Disparities in healthcare negatively impact all clinical outcomes, and thus 38 provisions to secure equitable healthcare and comparable health outcomes for vulnerable groups 39 are necessary. The scientific and clinical efforts toward addressing this are increasing and 40 multiple approaches to democratize care are being studied. 7 One approach is the opportunity for 41 healthcare workers, researchers, and policymakers to adopt innovative virtual care and remote-

Eligibility Criteria 100

Using a priori developed selection criteria, we included studies reporting on the use of virtual 101 care technologies in the context of patients in rural areas of Canada living with CVD. We used 102 the definition of CVD outlined by the World Health Organization's International Classification 103

of Diseases Tenth Edition (ICD-10), which encompasses all diseases of the circulatory system, 104

primarily: 1) coronary artery disease, or ischemic heart disease, caused by low myocardial 105 perfusion, and thus precipitating angina, myocardial infarction, and/or heart failure. 2) 106 cerebrovascular disease, including disorders that affect the blood supply to the brain, including 107 stroke and transient ischemic attack, and 3) peripheral artery disease, involving the limbs or 108 claudication in peripheral vasculature. Additionally, hypertension, valvular pathologies, aortic 109 aneurysms, and cardiac arrhythmias were all considered to be cardiovascular pathologies that fit 110 this definition. 20 111 112

This review includes all study designs, including quantitative pilot and retrospective comparison 113 studies, and qualitative analyses of the various aspects involved with the adoption of virtual care 114 technologies by healthcare providers, patients, and their families. Therefore, the population of 115

interest included patients diagnosed with CVD or individuals caring for patients diagnosed with 116 CVD at the time of study. We only included studies that explicitly mentioned rurally located 117 patients living in Canada, as the economic and political climate of a particular healthcare 118 network has proven to be a critical factor regulating how these virtual care technologies are 119 being disseminated and studied. Despite this, in some subsections, we reflect on Canadian 120 studies that do not explicitly focus on rural patients in order to contextualize the state of the 121 technology for a given disease. The articles also had to have been published in English within the 122 last 10 years, due to the fact that the technology is rapidly evolving, and older technologies are 123 becoming irrelevant. 124 125

Literature Search Strategy 126

Literature search strategies were developed with the assistance of an experienced information 127 services librarian (JP) who reviewed and refined the search criteria through iterative discussion. 128 We adopted relevant elements of the Preferred Reporting Items for Systematic Reviews and 129

Meta-Analyses (PRISMA). 21 A search of the literature was performed by the primary author 130 (RB) in May of 2020 using PubMed ©, Embase ®, and the Cochrane Central Register of 131

Controlled Trials (CENTRAL) ©. All articles that listed in the title or abstract the terms 132 "telehealth," "omnicare," "e-medicine," "electronic medicine," "remote consultation," or 133 "telemedicine" were linked through the Boolean operator "and" to rural-patient-identifying terms 134 ("rural," "remote," "distance," "rural population," and "rural health services"), as well as the 135 terms "Canada," and terms relating to the diseases of interest ("hypertension" or "cardiovascular 136 disease"). MeSH terms were used where appropriate and when possible. Using the features built 137 into each of these respective databases, the results were limited to studies published in English 138 within the last 10 years before being imported into Covidence ©. 139 140

Study Selection 141

Upon being imported into the review software, any duplicate articles were automatically 142 removed. The remaining titles and abstracts were screened for relevance to the research question 143 by the primary author (RB). Articles were removed if they did not meet the a priori defined 144 criteria. The full texts of each of the remaining articles were then individually obtained and 145 reviewed in-depth to determine their applicability. At this stage, each article was either removed, 146 or included and subsequently categorized based on the subtype of CVD in the study. A 147 miscellaneous category was created for studies that included multiple CVD subtypes. A total of 148 166 citations were identified and assessed for eligibility, yet only 36 studies met the inclusion 149 criteria and are discussed in this review. (Figure 2 ) 150 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Columbia. Their goal was to better understand the role of virtual care in CVD management, the 167 challenges to its adoption, and incentives that may increase its use among this population. The 168 findings suggest that both healthcare providers and patients supported the use of virtual care, 169

with the greatest benefits derived from the ability to share patient data and support patient self-170 management. Two concerns commonly expressed were the accuracy of patient self-reported data 171 and security, therefore the authors state that support for implementing such systems needs to be 172 tempered by a clear understanding of how these concerns will be mitigated. 22 Some reassurance 173 may be derived from the fact that many of these systems include automatic vital sign reporting to 174 the provider (as well as an option for manual input by the patient), and most devices adhere to 175 federal regulatory standards with respect to privacy and security. Further support for the role of 176 virtual care among rural patients comes from Cameron et al., who trialed a chronic disease self-177 management program in 13 rural and remote communities in Northern Ontario over a 9-month 178 period. A total of 213 individuals with diagnoses of chronic lung disease, CVD, stroke, or 179 arthritis were included in the study. While their goal was to better understand the psychological 180 mechanisms underlying the effectiveness of the program itself (rather than its delivery), the fact 181 that it was successfully conducted in this manner alone is encouraging. Specifically, the results 182 of this study show that virtual care initiatives can be a viable means of overcoming geographic 183 barriers for rural patients, and that patients and providers in rural areas may be uniquely 184 receptive to these innovations. Outcomes produced from these programs, including those related 185

to self-efficacy, mental-and physical-health status, can be comparable to in-person programs, 186 7 thereby enhancing the overall reach and equity of healthcare services. 23 Other evidence shows  187  that virtual care technologies used with regular exercise can improve patient cardiometabolic risk  188  profiles; Stuckey and colleagues investigated the effects of an exercise prescription alone  189  compared with a program supported by virtual care technology to improve cardiometabolic risk  190 factors in rural community-dwelling adults. This work, however, seems to be ongoing, as only 191 the rationale for this project could be sourced. 24 be discharged from the emergency department with home monitoring in order to reduce 220 hospitalization. 30 Given these preliminary results, we look forward to the pending release of a 221 peer-reviewed publication containing the results of this study. 222 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. CIED follow-up clinics as standard of care. The report also provides advice for the proper 258 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. atrial fibrillation (AF), specifically. In a preliminary study, thematic analysis of semi-structured 285 interviews with 14 patient and physician stakeholders revealed a high degree of variability in 286 receptiveness to virtual care. This was reported to be a result of differences in past experiences 287 with virtual care, in perceived adequacy of rural health services, and in perceived gaps in AF 288

care. 40 In a follow-up study with over 10-fold more patients (n=116) from three rural 289 communities, there were similar problems in managing AF. As it relates to virtual care, these 290 researchers found that access to primary and cardiology care was a recurring challenge, and 291 emergency department use was highly contentious but often the only option for accessing care. 292

Primary care physicians were generally comfortable managing AF but varied in their reasoning 293

for making referrals to specialists, often reserving them for complex situations to avoid the need 294 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this this version posted December 19, 2020. ; https://doi.org/10.1101/2020.12.17.20248333 doi: medRxiv preprint for patient travel. The patients and providers supported a broad approach to virtual care of AF 295 that is tailored to be inclusive of patients living in a rural demographic and thereby preserve the 296 vital role of primary care physicians. 41 297 298

Ischemic Heart Disease Interventions 299

Accurate and efficient interpretation of pre-hospital 12-lead electrocardiograms (ECGs) has 300

shown to produce favourable patient outcomes as it reduces the delay to reperfusion through 301 fibrinolysis or percutaneous coronary intervention (PCI) therapies. 42 Tanguay and colleagues  302 reported on a virtual care-based STEMI detection program used throughout rural Quebec. This 7-303

year retrospective study included 728 patients with suspected STEMI who were transported by 304

EMS. The transmission of an ECG every two minutes allowed for remote interpretation of 305 abnormalities by a physician to discern between patients with a STEMI and those with a non-306 STEMI. The system enabled remote diagnosis of STEMI in 8.1% of patients during transport 307

following an initial non-STEMI diagnosis. Thus, serial monitoring of these dynamic changes can 308 allow for more rapid diversion to primary PCI facilities, potentially improving outcomes. 42 Such 309

an approach could also lend itself well to machine learning decision support systems that 310

improve triage or follow-up. 311 312

The American Heart Association guidelines recommend that the time between first medical 313 contact and balloon inflation for STEMI patients should not exceed 90 minutes. 43 However, this 314

is not realistic for many rural health systems, leading to increased morbidity and mortality for 315 patients in these areas. The same group in Quebec also strove to address this issue by using 316

virtual care services to reduce pre-hospital delays and make timely STEMI diagnoses. Over a 317 similar 7-year time period, their retrospective data of 208 STEMI patients demonstrated that 318

14.9% were already on their way to a hospital with PCI capabilities, 75.0% were re-routed to a 319 PCI centre, and 10.1% were directed to the nearest hospital. All patients but one arrived at the 320 PCI centre within the guideline recommended 60-minute pre-hospital care interval. This study 321 further illustrates that virtual care can help give timely access to PCI for rural populations that 322

would not otherwise have access to this treatment. 44 Integrating virtual care with paramedic and 323 emergency departments can further augment this capacity to deliver on-time care to rural 324 patients. Despite this however, one could argue that truly remote patients will never be able to 325 reach a PCI centre within the recommended time window, and thus these results may not be 326 applicable. 327 328

Following an acute event of cardiac ischemia, cardiac rehabilitation programs, consisting of a 329 combination of lifestyle and risk-factor management, can improve psychosocial outcomes and 330 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (DREAM)-global study to improve hypertension awareness, treatment, and management in 366 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. their study suggest that this training system facilitated efficiencies and standardization of practice 400

to ensure optimal acute stroke management. 58 Taralson and colleagues also studied a similar 401 training protocol applied in Alberta. They identified that an enthusiastic local leadership team, 402 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. There is a need for CT-scans to assess cerebrovascular accidents to rule out brain haemorrhage 431 risk prior to thrombolysis. This expensive equipment is not widely available in rural areas and 432 remote healthcare sites, yet portable CT-scanners are brought into these rural sites and can be 433 operated after minimal training. A portable CT-scanner at a remote site was implemented in the 434 evaluation of patients who were not within timely reach of stroke experts. 66 Recently, a CT-435 equipped stroke ambulance was used to enable brain imaging at the patient's location. This 436 example of advanced paramedic technology suggests the potential for decentralizing care in 437 remote areas to bring the "hospital to the patient." While initial success has been documented, 438 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. participants reported as willing to recommend the system to others. As is a common theme in 459 this review, healthcare, community, and virtual care partnerships were critical to the success of 460 this program. 70 Linkewich and colleagues reported on an analogous virtual care tool used to 461 conduct OT home safety assessments for a similar patient population. The OTs who participated 462 reported confidence in making practice recommendations using the program, however, a 463 comment about needing to "sense" the client in a different way was repeatedly made, suggesting 464 that reduced non-verbal body language could be a disadvantage of the tool. The client and all 465

OTs were willing to recommend the virtual assessment system. Audio quality was also reported 466 to be problematic, as in the previous study. 71 Technology based experiential quality is a 467 surmountable issue and can be overcome through cell-tower and emerging satellite high-speed 468

connectivity. These findings also emphasize the goal of virtual care should not be to eliminate in-469 person systems but rather focus them and integrate with it for productivity, efficiency, and 470 patient outcome or experience benefit. 471 472

Moving On after Stroke (MOST®) is a group-based, self-management program for stroke 473 survivors and their caregivers consisting of information sharing, facilitated discussions, goal-474 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. about their experiences using a system designed specifically for low-cost consumer technologies. 497

While they found that the delivery of rehabilitation services using these technologies was both 498 feasible and desirable by many stroke survivors, 71% of respondents believed their quality of 499 care would be less than in-person rehabilitation. Therefore, the authors concluded that virtual 500 care should augment and not replace in-person rehabilitation, but in cases where in-person 501 rehabilitation is neither accessible nor possible, then virtual care is an acceptable substitution. 74 502

Lastly, Appireddy, et al. reported results from a 6-month study using virtual care for post-stroke 503 follow-up care throughout the Kingston Health Sciences Centre in Ontario. This study included 504 75 participants (of which 39% were rural) and they found that: 1) There was a statistically 505 significant shorter wait-time for a virtual appointment compared to in-person (median 60 vs 78 506 days).

2) The virtual care visits were also shorter in duration, taking on an average of 10 minutes 507

to deliver follow-up care with a high degree of patient satisfaction versus an average of 90 508 minutes for in-person care. 3) On average, the total time saved by patients per visit was 80 509 minutes, of which 44 minutes was travel time. 4) Travel distance avoided by the patients was an 510 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this this version posted December 19, 2020. ; https://doi.org/10.1101/2020.12.17.20248333 doi: medRxiv preprint average of 30.1 km. 5) The estimated total out-of-pocket cost savings for patients per visit was 511 $52.83. 6) The estimated savings (opportunity cost for in-person outpatient care) for their entire 512 virtual care pilot project was $23,832 -$28,584 CAD. The patient satisfaction with the virtual 513 system was good compared with their prior personal experience with in-person outpatient care. 75 514

A point worthy of exploration is the discrepancy in patient cost-savings mentioned in this study 515 as compared with the figures cited previously of $445 and $500 CAD. The fact that this study 516 contained only 39% rural patients, whereas the other two studies were entirely composed of rural 517

patients may indicate that much of the cost-savings are likely related to food, parking, 518 accommodation, and not simply mileage. This discrepancy may also reflect the fact that rural 519

Saskatchewan and Alberta have greater cost to distance travel ratios than Ontario, or perhaps the 520 cost discrepancy is due to lack of inflation adjustment. Incorporating health economic analyses to 521 virtual care pilots, implementation, monitoring should be emphasized. Health value 522 demonstration initiatives are ideally well powered and longitudinal partnerships between 523 academic institutes and health authorities. 524

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To our knowledge, this is the first review of recent publications that examines the use of virtual 526 care technology seeking to benefit patients with CVD who are living in rural Canadian locations. 527 We have attempted to understand the effectiveness of the various interventions, which have 528 generally had positive effects among the patient population of interest. The specific subjective 529 benefits of virtual care include reduced hospitalization and readmissions, improved mortality 530 rates, increased cost-effectiveness for patients and hospitals, improved quality of life for patients, 531

and an increase in self-management of CVD. Further benefit is derived through better disease 532 prevention and increased patient investment in their health span. Virtual care is not a panacea for 533 all rural medicine needs. However, it is clear that value is being extracted, predominantly by 534 three Canadian provinces (BC, ON, and QC), which is surprising since these provinces have the 535 greatest urban concentrations of people. 76 These provinces also account for the majority of 536 research pertaining to rural medicine in general, which indicates potential inequities in medical 537 research contrary to the objectives of the Canada Health Act. Remarkably, the Western Prairies, 538

Territories, and the Atlantic provinces (with seemingly the most need and the most to gain from 539 virtual care innovations) are not well represented in this subsection of the literature. In the 540

Canadian context, this puts all provinces at a disadvantage by being over-reliant on health 541 transfers from the federal government instead of leadership by strength. Establishing an online, 542 virtual care institute amongst low population density provinces might be possible, yet most 543 supercluster and centers of excellence are concentrated in dense urban zones. Exploring this 544 potential inequity from a legal, social and humanities perspective should be of interest to 545 researchers moving forward. 546 547

While still largely unadopted on a national level, the data indicates that systems in place for 548 acute pathologies like stroke and STEMI are the most well-established and far-reaching, while 549 systems focused on more chronic subtypes of CVD like HF, hypertension, and arrhythmias, are 550 lagging and largely remain in the pilot phase. This is an important point to highlight, as the 551 management of chronic disease is likely to have the greatest impact. Studies performed within 552 government by health departments or industry in the form of white papers, were inaccessible for 553 review. As a result, very few randomized control trials were identified and much of the work in 554 this area is only being shared in conference proceedings. In the wake of the COVID-19 555 pandemic, this dynamic is likely to rapidly evolve given the expedited policy changes 556

surrounding the use of virtual care technologies. 77 Innovative solutions like the ones discussed 557

here are now of critical importance given their ability to reduce contact between healthcare 558 providers and vulnerable patient populations. 559 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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Overall, there is an interest to support virtual care among the stakeholders investigated in this 560 study, despite some perceived barriers when compared to in-person approaches to healthcare. 561

Despite this enthusiasm, there is still insufficient evidence to objectively support the outcomes, 562 health economics, physician/patient-satisfaction, and privacy concerns due to a lack of trials and 563 peer-reviewed evidence at this time. CVD risk factor management using virtual care needs peer 564 reviewed study in the Canadian context to build an evidence base that informs policy 565 development. Such studies should emphasize the rationale, define the intended benefit and the 566 comparator arm, and address cost-effectiveness or any barriers to implementation. Until that 567 time, it remains presumed but uncertain that virtual care in Canada can assist in the prevention of 568 CVD, when compared with more specified conditions requiring interventional support. 569 570

Despite the fact that the collective studies lacked the desired scientific rigour, or are of limited 571 meta-data, the qualitative insights provide valuable recommendations for researchers planning to 572 deploy virtual care technologies in the future. These have been summarized in Figures 3 and 4 . 573

Briefly, a common point of note was the need to involve patients as stakeholders during the 574 planning of virtual care distribution strategies. Kim and colleagues provide insightful 575 commentary as to how best to involve patients. 78 Another was the need to clarify the roles and 576

responsibilities of all members of the healthcare team related to the virtual care system, 577

specifically stressing who will be responsible for the training of patients and informal care 578

providers. This may represent an obstacle best overcome by online education videos or other 579 patient assistive products and services. Role clarification is needed between the payer and the 580 provider for services and should be explored in future studies. Canada remains predominantly a 581 single/public-paying system and is slow to integrate innovations predominantly developed by the 582 private sector. Establishing a priori criteria to be met by the private sector to deliver virtual care 583 would be welcomed, as the preferences of payers are a critical policy consideration for health 584 authorities. Establishing victory conditions (that is, clear target endpoints), would avoid any 585 further languishing of incorporating healthcare technology innovation that is greatly needed, and 586 so as to be prepared for crisis rather than react to it in the example of implementing virtual care 587 during a pandemic. 588 589

The current disparities in health metrics suggest that patients in rural areas, particularly 590

Indigenous nations, desire greater diversity in healthcare delivery, desire to contribute culturally 591 and require specific accommodations. In addition to virtual care services, advanced care 592 paramedics, mobile care units, increased scope of practice for rural pharmacists, augmented 593 extramural nursing and home care options, and physician assistants, could all contribute to rural 594 healthcare teams. Many of these auxiliary topics, in addition to the challenges of policy and 595 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. prioritize high-risk high-reward regions with considerable rural populations to maximize early 649 returns on investments in virtual care. 650 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. conflicts of interest to disclose relevant to the present work. None of these enterprises played a 672 role in the design, data collection, analysis, or interpretation of this literature review, or in 673 preparation of this manuscript. 674 675 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this this version posted December 19, 2020. ; https://doi.org/10.1101/2020.12.17.20248333 doi: medRxiv preprint  F  i  g  u  r  e  3  .  S  u  m  m  a  r  y  o  f  v  i  r  t  u  a  l  c  a  r  e  r  e  c  o  m  m  e  n  d  a  t  i  o  n s .

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The copyright holder for this this version posted December 19, 2020. ; https://doi.org/10.1101/2020.12.17.20248333 doi: medRxiv preprint  F  i  g  u  r  e  4  .  S  u  m  m  a  r  y  o  f  p  r  a  c  t  i  c  a  l  o  b  j  e  c  t  i  v  e  s  f  o  r  f  u  t  u  r  e  v  i  r  t  u  a  l  c  a  r  e  p  r  o  g  r  a  m s .

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Canadian Institute for Health Information, Disparities in Primary Health Care Experience 683

Among Canadians with Ambulatory Care Sensitive Conditions

Reducing Potentially Excess Deaths from the Five Leading Causes of 685 Death in the Rural United States

Does geography matter in mortality? An 687 analysis of potentially avoidable mortality by remoteness index in Canada

Disparity in cancer care: a Canadian perspective

Access to Routine Medical Care and Cardiovascular Disease Outcomes in a 692

Rural and urban disparities in the care of Canadian patients with 694 inflammatory bowel disease: a population-based study

Ensuring equitable access to care: Strategies for

Health System Planners, and the Medical Profession

Canadian Institute for Health Information, Health Care in Canada: A Focus on Wait 699 Times

Telemedicine on the rise but lagging in Canada

e-Health in cardiology: remote patient 703 management of heart failure patients. e-Journal of Cardiology Practice

Unlocking the Potential of Physician-to-Patient 709

Board on Health Care Services; Institute of Medicine, The Evolution of Telehealth: Where 711

Have We Been and Where Are We Going? The Role of Telehealth in an Evolving Health 712 Care Environment: Workshop Summary

Telehealth, Mobile Applications, and Wearable Devices are Expanding

Cancer Care Beyond Walls

A comparative risk assessment of burden of disease and injury attributable 716 to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis 717 for the Global Burden of Disease Study

evidence-based guideline for the management of high blood 719 pressure in adults: report from the panel members appointed to the Eighth Joint National 720

Cost-effectiveness of home blood pressure telemonitoring and case 722 management in the secondary prevention of cerebrovascular disease in Canada

Global Burden of Disease Study trends for Canada from 1990 to 725

Preferred reporting items for systematic reviews and meta-analyses: the 729 PRISMA statement

Internet-based support for cardiovascular disease management

In this together": Social identification predicts health outcomes (via 733 self-efficacy) in a chronic disease self-management program

A lifestyle intervention supported by mobile health technologies to 736 improve the cardiometabolic risk profile of individuals at risk for cardiovascular disease 737 and type 2 diabetes: study rationale and protocol

Conceptual model for heart failure 739 disease management

Cardiovascular nurses: The key factor in the success of the first Canadian 741 heart failure remote monitoring clinic

A first in Canada: The St. Boniface Hospital heart failure remote 744 monitoring clinic experience

The effectiveness of telehealth nursing in heart failure self-management

Supporting Heart Failure Patient 748 Transitions from Acute to Community Care with Home Telemonitoring Technology: A 749 Protocol for a Provincial Randomized Controlled Trial (TEC4Home)

TEC4Home heart failure: Using home telemonitoring to 752 decrease ED readmissions and clinical flow

Implementation factors and their effect on e-Health service adoption in 755 rural communities: a systematic literature review

Rural-Urban Comparison of Telehome Monitoring for Patients 757 with Chronic Heart Failure

Telemedicine Association

Guidelines for pacemaker follow-up in Canada: a consensus statement 760 of the Canadian Working Group on Cardiac Pacing

Guidelines for implantable cardioverter defibrillator follow-up in

Canada: a consensus statement of the Canadian Working Group on Cardiac Pacing

Position Statement on the Use of Remote Monitoring for Cardiovascular Implantable 767

Electronic Device Follow-up

Telehealth arrhythmia clinic: Initial experience report

Manchak A.)

Remote monitoring for ICD follow-up: Connecting technology, clinic 772 processes, patient care and best practice

Evaluating the integration of remote monitoring for cardiovascular 775 implantable electronic device follow-up

A usability study of patients setting up a cardiac 778 event loop recorder and BlackBerry gateway for remote monitoring at home. Telemedicine 779 Journal and e-Health from the American Telemedicine Association

Planning Telehealth for Older Adults with Atrial Fibrillation in Rural 782 Communities: Understanding Stakeholder Perspectives

Atrial fibrillation care in rural communities: a mixed methods study of 785 physician and patient perspectives

ACCF/AHA guideline for the management of ST-elevation 789 myocardial infarction: a report of the American College of Cardiology 790

Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 791 2013

All rights reserved. No reuse allowed without permission

Rural Patient Access to Primary Percutaneous Coronary Intervention 793 Centers is Improved by a Novel Integrated Telemedicine Prehospital System

The Delivery of Cardiac Rehabilitation Using Communications Technologies: 796 63

Thrombolysis using telehealth has comparable results to non-841 telehealth thrombolysis across northern Alberta: The Alberta provincial stroke strategy

Acute stroke care: Telestroke vs. on-site stroke specialist care. Results 844 from the Ontario telestroke experience

Introduction of portable computed tomography scanners, in the treatment 846 of acute stroke patients via telemedicine in remote communities

The mobile stroke unit and management of acute stroke in 849 rural settings

A smartphone client-server teleradiology system for primary 851 diagnosis of acute stroke

Developing an aboriginal stroke strategy in Northwestern Ontario

Tele-rehab: The feasibility of using 855 telemedicine to deliver interprofessional stroke rehabilitation consultations in northern, 856 rural and remote communities

Remote participants' experiences with a 861 group-based stroke self-management program using videoconference technology. Rural 862 and Remote Health

The Saskatchewan cerebrovascular center: 864 Telehealth pilot project

A telehealth intervention to promote healthy lifestyles after stroke: 866 the stroke coach protocol

Home Virtual Visits for Outpatient Follow-Up Stroke Care: Cross-868 Sectional Study

Rural and Remote Cardiology During the COVID-19 Pandemic

Cardiac Society of Australia and New Zealand (CSANZ) Consensus Statement

A Novel Stakeholder Engagement Approach for Patient-centered

Treating the right patient at the right time: access to heart failure care. Can 877

Average Annual Number of Physician Visits per Capita

Single screening versus conventional double screening for study 885 selection in systematic reviews: a methodological systematic review