key: cord-0812814-ogdd1ulw
authors: Perkins, Ryan C.; Davis, Jaclyn; NeSmith, Andrew; Bailey, Julianna; Powers, Michael R.; Chaudary, Nauman; Siracusa, Christopher; Uluer, Ahmet; Solomon, George M.; Sawicki, Gregory S.
title: Favorable Clinician Acceptability of Telehealth as Part of the Cystic Fibrosis Care Model during the COVID-19 Pandemic
date: 2021-03-30
journal: Annals of the American Thoracic Society
DOI: 10.1513/annalsats.202012-1484rl
sha: a42e5183d55f7d41c4f4e44ed0ce1b2b0edb4789
doc_id: 812814
cord_uid: ogdd1ulw

nan

perceptions surrounding telehealth experiences, and 3) preferences for future telehealth care (Table 1 ). An initial survey to establish perceptions of telehealth experience was distributed from May to June 2020. A follow-up survey including identical questions and themes was redistributed from August to September 2020. The follow-up survey sought to investigate the durability and consistency of clinician perceptions following 6 months of telehealth experience. The survey was administered using Google Forms (Google), descriptive statistics and nonparametric test of hypotheses were performed using STATA 15 (StataCorp.), and figures were created using GraphPad Prism 8.4 (GraphPad Software).

A total of 80 clinicians from medium and large CF programs in the Northeast, Midwest, South, and Pacific Northwest completed the initial survey and 63 the follow-up survey ( Figure 1 ). Most (90%) had never previously used telehealth, 83% felt they received adequate training before beginning telehealth, and 65% reported completing more than 10 visits at the time of the survey. Zoom was the most commonly available (56% initial, 57% follow-up) platform for visits. On initial assessment, a variety of interdisciplinary structures and single-discipline visits were used; however, on follow-up assessment, an interdisciplinary asynchronous format (multiple clinicians evaluated the patient sequentially during the same visit) was predominantly used (48%). The majority of visits (89% initial, 95% follow-up) incorporated audio plus video connectivity, were predominantly accessed by computer (75% initial, 89% follow-up), and were conducted from the clinician's home (74% initial, 57% follow-up). At 6 months, 83% endorsed experiencing a technical complication at least once following implementation, although 88% experiencing difficulty were able to complete the encounter. Barriers to previous telehealth implementation and concerns about missing assessments are presented for the cohort and for pediatric and adult clinicians in Figure 2 . Despite concern about missing assessments, 78% initially felt that none or few of the patients evaluated by telehealth should have been evaluated in person. This decreased to 68% on follow-up assessment (P = 0.4). Satisfaction (86% initial, 89% follow-up; P = 0.7), positive impact on clinician-patient relationship (58% initial, 57% follow-up; P = 1), and improved efficiency (56% more efficient than in-person visits on both assessments; P = 0.9) remained consistent across both assessments.

If future telehealth visits were offered, clinicians preferred that some/most visits (96% initial, 99% follow-up; P = 0.1) be performed using telehealth. Quarterly (95% both assessments; P = 1) and hospital follow-up (69% initial, 61% follow-up; P = 0.4) were identified as the most appropriate future visit types. Interdisciplinary synchronous structure (44%) was initially preferred for future visits, but interdisciplinary asynchronous structure (58%) became preferred on repeat assessment (P = 0.03). Nearly all respondents (92% initial, 89% follow-up; P = 0.6) were interested in technology to remotely assess oximetry or lung function.

The COVID-19 pandemic led to healthcare delivery reorganization and rapid telehealth implementation for routine CF care. Our crosssectional survey of clinicians indicates that although most had no prior experience using telehealth, clinicians found it to be highly satisfying and efficient and to have improved the clinician-patient relationship. Currently, no standardized format for telehealth delivery exists for CF or other pulmonary diseases. Our findings indicate that clinicians prefer the interdisciplinary care model and desire to continue to use telehealth for future routine ambulatory care and suggest durability of perceptions and preferences over the initial 6 months of use. Of the interdisciplinary care models, the asynchronous model became preferred over time by clinicians. This is likely related to improved clinician comfort with telehealth, adaptation of the telehealth care delivery model to improve visit efficiency, and its similarity to care delivery during in-person visits.

Our study also revealed an increase in perceived barriers to telehealth use over time (Figures 2A and 2B ). In particular, it was anticipated that clinicians would have concerns surrounding missing components of routine assessment. When evaluating concern for these missing components by subtype ( Figures 2C and 2D) , pediatric and adult clinicians exhibited similar levels of concern over time.

Interestingly, when asked about the perceived barrier these missing components imparted to telehealth use, adult clinicians perceived the barrier to decline whereas pediatric clinicians perceived an increase over the 6-month period. This may be related to pediatric clinicians' concerns about technological limitations, concern surrounding missing the acquisition of new pathogens, or the potential for delayed diagnosis of a subacute exacerbation. Regarding the growing concern for technological limitations, it is unclear if these concerns are related to lack of institutional support, limitations among patients/families to technology to access visits, deficiencies in software interface, or a combination of the above. Interestingly, technological limitations appeared to be an area of growing concern among pediatric clinicians but not among adult clinicians. Future investigations should seek to further characterize these barriers, including the role of social determinants to help ensure the equitable provision of care. Furthermore, growing concerns surrounding regulation and reimbursement highlight the need for future policy and advocacy investigations.

Telehealth also allows for opportunities for technology innovation. For example, the majority of clinicians expressed that lack of pulmonary function testing testing imparted a moderate or greater difficulty to patient care. Clinicians also endorsed interest in technology to assess lung function remotely, and the provision of home spirometers via a current Cystic Fibrosis Foundation initiative could further enhance telehealth services. However, questions still remain about the accuracy of home spirometry (20, 21) . The impact of telehealth on clinical and patient-reported outcomes remains unknown. Future studies should continue to explore the integration of innovative technologies into the care delivery model and focus on other areas of clinician concern such as microbiological culture acquisition and potential implications of Pseudomonas eradication in children. Future investigations should address these gaps and continue to explore avenues to optimize the CF care delivery model (i.e., the optimal number of visits to perform by telehealth and alternative models of telehealth care delivery such as hybrid visits). Hybrid models may alleviate perceived barriers to care noted in our study by allowing a clinician to assess a patient in person, while also minimizing exposures.

Our study has several limitations. First, our study includes a small sample size of clinicians and may be subject to ascertainment bias. Furthermore, the second survey had reduced response at one of the survey sites, which is likely secondary to survey fatigue. The multicenter design of our study did, however, allow for sampling of clinicians from different regions and care center sizes across the country. Second, our study lacks long-term perception data, and it is feasible that clinician perception will change over time. We will collect long-term data to further assess the impact of continued exposure on the durability of perceptions. Finally, owing to the design of our study, we do not know the response rate of clinicians and cannot be sure how representative the responses are of the total experience of telehealth at the centers we surveyed.

In conclusion, we characterized telehealth usage patterns and preferences among a cohort of CF clinicians. Telehealth was well accepted, and our findings highlight the utility of telehealth for enhancing interdisciplinary CF healthcare delivery. Future studies are needed to understand its impact on clinical and patient-reported outcomes.

Author disclosures are available with the text of this letter at www. atsjournals.org.

assessing the temporal trends, only full calendar years were included (January 1, 2015-December 31, 2017), and thus only 522 patients are included in those results.

Definitions. A CPSI was defined by clinical signs and/or symptoms consistent with a pleural infection and pleural fluid demonstrating either a positive Gram stain or culture, the presence of grossly purulent drainage, lactate dehydrogenase .1,000 IU/L, glucose ,60 mg/dl, pH ,7.20, or loculations. Two phases of CPSIs were captured, as follow: complicated (the above definition without pus) and empyema (pus present).

A standard regimen of IPET (per MIST2 guidelines) was defined as twice daily administration of dual-agent alteplase and Dornase a for a total of 5-6 doses. Any other dosing regimen was defined as alternative. Crossover management was defined as either IPET after surgical management or surgery after IPET management.

Statistical analysis. Descriptive data were summarized by median (interquartile range) for continuous data and as count (percentage) for categorical data. Data between groups were compared using the Mann- 

Telehealth in urology after the COVID-19 pandemic

Early clinical experience using telemedicine for the management of patients with varicose vein disease

Telemedicine in a pediatric headache clinic: a prospective survey

Rapid utilization of telehealth in a comprehensive cancer center as a response to COVID-19: cross-sectional analysis

COVID-19-a guide to rapid implementation of telehealth services: a playbook for the pediatric gastroenterologist

Telemedicine in the perioperative experience

Emergency video telemedicine consultation for newborn resuscitations: the Mayo Clinic experience

Departmental experience and lessons learned with accelerated introduction of telemedicine during the COVID-19 crisis

Implementing telemedicine in response to the COVID-19 pandemic

Addressing health disparities in rural communities using telehealth

Telemedicine in the OECD: an umbrella review of clinical and cost-effectiveness, patient experience and implementation

Patient and clinician experiences with telehealth for patient follow-up care

Patients' satisfaction with and preference for telehealth visits

A cost minimisation analysis of a telepaediatric otolaryngology service

Evaluating barriers to adopting telemedicine worldwide: a systematic review

The use of telehealth (text messaging and video communications) in patients with cystic fibrosis: a pilot study

Telehealth clinics increase access to care for adults with cystic fibrosis living in rural and remote Western Australia

A feasibility study of urgent implementation of cystic fibrosis multidisciplinary telemedicine clinic in the face of COVID-19 pandemic: single-center experience

Telehealth implementation in cystic fibrosis care during COVID-19: the clinician experience. Poster session abstracts

FEV1 measurement at home versus measurement in the hospital in children with asthma and cystic fibrosis

Implementation of pediatric home spirometry: potential height bias

Healthcare Network Review To the Editor: Management of complicated pleural space infections (CPSIs) requires antibiotics and drainage for effective treatment. When this fails, surgical debridement has been the standard of care. Even with the MIST2 (second Multicenter Intrapleural Sepsis Trial) in 2011 demonstrating effective fluid drainage using combination intrapleural enzyme therapy (IPET), updated surgical guidelines for CPSIs recommend debridement as first-line therapy, whereas the British Thoracic Society suggests that not all patients require surgery (1-3). We aimed to describe the temporal trends in primary treatment for CPSIs and the variation in IPET adoption and to identify the specialty of management teams within a large multicenter community-based healthcare network

were identified via billing codes. Of 1,640 patients, 1,074 were excluded for the following reasons: prior thoracic surgery (n = 456), malignant/paramalignant pleural effusion (n = 201), hemothorax (n = 186), incomplete medical records (n = 117), esophageal perforation (n = 89