The objective of this study was to determine if video otoscope still images (640 x 480 pixel resolution) of the tympanic membrane following surgical placement of tympanostomy tubes are comparable to an in-person microscopic examination. Forty patients having undergone tympanostomy tube placement in both ears were independently examined in-person by two otolaryngologists and imaged using a video otoscope and telemedicine software package. The two physicians later reviewed images at 6 and 12 weeks. Physical examination findings and diagnosis were documented and compared for their concordance using kappa statistics. For both physicians, the intraprovider concordance between the in-person examination and the corresponding image review was high for each of the physical examination findings: Tube In 93-94% (K 0.85-0.87), Tube Patent 86-93% (K 0.74-0.85), Drainage 94-98% (K 0.42-0.66), Perforation 85-98% (K 0.40-0.84), Granulation 95-99% (K -0.01 to 0.00), Middle Ear Fluid 89-91% (K -0.03 to 0.50), and Retracted 89-94% (K 0.13-0.43). These agreement rates are similar to the normal interprovider concordance observed when two physicians independently examined the same patient in-person for physical exam findings: Tube In 96% (K 0.93), Tube Patent 94% (K 0.88), Drainage 96% (K 0.56), Perforation 90% (K 0.60), Granulation 96% (K 0.39), Middle Ear Fluid 88% (K 0.14), and Retracted 91% (K 0.43). For both physicians, the intraprovider diagnostic concordance between the in-person examination and the corresponding image review was high 79-85% (K 0.67-0.76). The interprovider diagnostic concordance for the in-person exam was 88% (K 0.81). The interprovider diagnostic concordance when two physicians independently reviewed all images was 84% (K 0.74), and 89% (K 0.80) when poor images were excluded. This study demonstrates that physician review of video otoscope images is comparable to an in-person microscopic examination. Store-and-forward video otoscopy may be an acceptable method of following patients post-tympanostomy tube placement.
Video-otoscopy images of the tympanic membrane are comparable to an in-person examination for assessment and treatment of patients following tympanostomy tubes. Store-and-forward telemedicine is an acceptable method of following patients post tympanostomy tube placement.
Audiology in rural Alaska has changed dramatically in the past 6 years by integrating store and forward telemedicine into routine practice. The Audiology Department at the Norton Sound Health Corporation in rural Nome Alaska has used store-and-forward telemedicine since 2002. Between 2002 and 2007, over 3,000 direct audiology consultations with the Ear, Nose, and Throat (ENT) Department at the Alaska Native Medical Center in Anchorage were completed. This study is a 16-year retrospective analysis of ENT specialty clinic wait times on all new patient referrals made by the Norton Sound Health Corporation providers before (1992-2001) and after the initiation of telemedicine (2002-2007). Prior to use of telemedicine by audiology and ENT, 47% of new patient referrals would wait 5 months or longer to obtain an in-person ENT appointment; this dropped to 8% of all patients in the first 3 years with telemedicine and then less than 3% of all patients in next 3 years using telemedicine. The average wait time during the first 3 years using telemedicine was 2.9 months, a 31% drop compared with the average wait time of 4.2 months for the preceding years without telemedicine. The wait time then dropped to an average of 2.1 months during the next 3 years of telemedicine, a further drop of 28% compared with the first 3 years of telemedicine usage.
This project increased access to otolaryngology services by having an audiologist travel to remote Alaska and communicate with an otolaryngologist using store-and-forward electronic consultation. The audiologist was instructed to effectively image appropriate parts of the otolaryngology exam and create telemedicine cases that included clinical histories, images, audiograms, tympanograms, otoacoustic emission testing and/or other documents. The otolaryngology consultants reviewed new referrals as well as follow up cases and made treatment and triage recommendations. Over a 57 month period, 54 trips were made to 14 villages providing 197 clinic service days. The 1,458 patient encounters resulted in referral for surgery or special diagnostic testing 26%, referral for monitoring 23%, starting of medications 19%, referral to regional ENT clinic 15%, and referral to another specialty 5%. Approximately 27% patients did not need to see the otolaryngologist and were triaged out of the specialty clinic. The total cost to run this project was $141,114. Travel was prevented for 85% encounters, resulting in travel cost avoidance in airfare of $496,420. These services were provided at a significantly lower cost and with fewer burdens to the patients when compared to the standard referral system. An audiologist that travels to remote locations and uses store-and-forward telemedicine can rapidly deliver otolaryngology services. This model is a proven mechanism of efficient healthcare delivery that may be expanded to other specialties.
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