Implementation of a Pediatric Telemedicine and Medication Delivery Service in a Resource-limited Setting: A Pilot Study for Clinical Safety and Feasibility

Klarman, Molly B.; Flaherty, Katelyn E.; Chi, Xiaofei; Cajusma, Youseline; Capois, Anne Carine; Dofiné, Michel Daryl Vladimir; Exantus, Lerby; Friesen, Jason; Rochars, Valery Madsen Beau De; Baril, Chantale; Gurka, Matthew J.; Becker, Torben K.; Nelson, Eric J.

doi:10.1016/j.jpeds.2022.12.005

Cited by 5 publications

(19 citation statements)

References 26 publications

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“…When no household visit Enrollment estimates. The enrollment size for this prospective cohort study was based on a larger census-based prospective cohort pilot study described previously 18 .…”

Section: Methodsmentioning

confidence: 99%

“…Workflow. The INACT2 TMDS workflow (Figure 1) was described previously 18 . In brief, (i) A parent contacted the TMDS.…”

Section: Methodsmentioning

confidence: 99%

“…Clinical procedures. Sample collection (stool, nasopharyngeal) and in-person measurements (vital signs and mid-upper arm circumference (MUAC)) have been described previously 26 Technology resources. Twilio Flex was used for call intake.…”

Section: (Which Was Not Certified By Peer Review)mentioning

confidence: 99%

“…The in-person exams resulted in amoxicillin removal for 9% (26) of cases and addition of amoxicillin for 3% (8) of cases. At 10 days, 95% (273) of cases included in these analyses were better/recovered.…”

Section: (Which Was Not Certified By Peer Review)mentioning

confidence: 99%

“…These findings should be viewed within the context of the study limitations. First, this prospective cohort study was nested within a larger study to determine the feasibility and safety of the TMDS model 18 . The approach allowed for adaptive and iterative components based on unexpected logistical and clinical challenges; minor modifications were made to call in-take logistics, and clinical approaches and resources.…”

Section: (Which Was Not Certified By Peer Review)mentioning

confidence: 99%

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Development and Evaluation of a Clinical Guideline for a Pediatric Telemedicine and Medication Delivery Service: A Prospective Cohort Study in Haiti

Klarman

Chi

Cajusma

et al. 2023

Preprint

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Objective: Despite the emergence of telemedicine as an important model for healthcare delivery, there is a lack of evidence-based telemedicine guidelines, especially for resource-limited settings. We sought to develop and evaluate a guideline for a pediatric telemedicine and medication delivery service (TMDS). Methods: A prospective cohort study was conducted at a TMDS in Haiti; children ≤10 years were enrolled. Among non-severe cases, paired virtual and in-person exams were conducted at the call center and household; severe cases were referred to the hospital. The primary outcome was the performance of the virtual exam compared to the in-person exam (reference standard). Findings: A total of 391 cases were enrolled. Among 320 cases with paired exams, no general World Health Organization (WHO) danger signs were identified at the household; problem-specific danger signs were identified in 6 cases (2%). Cohen's kappa for the designation of mild cases was 0.78 (95%CI 0.69-0.87). Among components of the virtual exam, the sensitivity and specificity of a reported fever were 91% (87%-96%) and 69% (62%-74%), respectively; the sensitivity and specificity of 'fast breathing' were 47% (21%-72%) and 89% (85%-94%), respectively. Kappa for dehydration assessments indicated moderate congruence (0.69; 95%CI 0.41-0.98). At 10 days, 95% (273) of the 287 cases reached were better/recovered. Conclusion: This study, and resulting guideline, represents a formative step towards an evidence-based pediatric telemedicine guideline built on WHO clinical principles. In-person exams for select cases were important to address limitations with virtual exams and identify cases for escalation.

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Section: Methodsmentioning

confidence: 99%

“…Workflow. The INACT2 TMDS workflow (Figure 1) was described previously 18 . In brief, (i) A parent contacted the TMDS.…”

Section: Methodsmentioning

confidence: 99%

Section: (Which Was Not Certified By Peer Review)mentioning

confidence: 99%

Section: (Which Was Not Certified By Peer Review)mentioning

confidence: 99%

Section: (Which Was Not Certified By Peer Review)mentioning

confidence: 99%

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Development and Evaluation of a Clinical Guideline for a Pediatric Telemedicine and Medication Delivery Service: A Prospective Cohort Study in Haiti

Klarman

Chi

Cajusma

et al. 2023

Preprint

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Evaluating the prerequisites for adapting a paediatric nighttime telemedicine and medication delivery service to a setting with high malarial burden: A cross‐sectional pre‐implementation study

Flaherty

Klarman

Zakariah

et al. 2023

Tropical Med Int Health

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ObjectiveWe sought to evaluate the prerequisites (demand, interest, feasibility) for adapting a paediatric nighttime telemedicine and medication delivery service (TMDS) to Ghana.MethodsA cross‐sectional survey of households and associated healthcare providers was conducted in urban and rural Ghana. Households were identified through randomised geospatial sampling; households with at least one child <10 years were enrolled. Household surveys collected information relating to demographics, household resources, standardised case scenarios, recent paediatric health events, satisfaction with healthcare access, and interest in TMDS intervention models. Providers were identified by households and enrolled. Provider surveys collected provider type, hours of operation, services, and opinions of a TMDS model.ResultsA total of 511 (263 urban, 248 rural) households and 18 providers (10 urban, 8 rural) were surveyed. A total of 262 health events involving children <10 years were reported, of which 47% occurred at night. Care was sought for >70% of health events presenting at night; however, care‐seeking was delayed until morning or later for >75% of these events; 54% of households expressed dissatisfaction with their current access to paediatric care at night; 99% of households expressed that a nighttime TMDS service for children would be directly useful to their families. Correspondingly, 17 of 18 providers stated that a TMDS was needed in their community; >99% of households had access to a cellular phone. All households expressed willingness to use their phones to call a TMDS and allow a TMDS provider into their homes at night. Willingness to pay and provider‐recommended price points varied by setting.ConclusionsPrerequisites for adapting a TMDS to Ghana were met. A nighttime paediatric TMDS service was found to be needed, appealing, and feasible in Ghana. These data motivate the adaptation of a TMDS to urban and rural Ghana.

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Development and evaluation of a clinical guideline for a paediatric telemedicine service in a low-resource setting

Klarman,

Chi,

Cajusma

et al. 2024

bmjpo

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ObjectiveTo develop and evaluate a guideline for a paediatric telemedicine and medication delivery service (TMDS).MethodsA clinical guideline for paediatric telemedicine was derived from the World Health (WHO) OrganizationIntegrated Management of Childhood Illness (IMCI) Handbook. The guideline was deployed at a TMDS in Haiti and evaluated through a prospective cohort study; children ≤10 years were enrolled. For non-severe cases, paired virtual and in-person examinations were conducted at the call centre and household; severe cases were referred to the hospital. The performance of virtual examination components were evaluated by comparison with the paired in-person examination findings (reference).ResultsA total of 391 cases were enrolled. Among the 320 cases with paired examinations, no general WHO danger signs were identified during in-person examinations; 5 cases (2%) required hospital referral due to problem-specific danger signs or other reasons for escalation. Cohen’s kappa for the virtual designation of mild cases was 0.78 (95% CI: 0.69 to 0.87). The sensitivity and specificity of a virtually reported fever were 91% (95% CI: 87% to 96%) and 69% (95% CI: 62% to 76%), respectively; the sensitivity and specificity of virtually reported ‘fast breathing’ were 47% (95% CI: 21% to 72%) and 89% (95% CI: 85% to 94%), respectively. Kappa for ‘no’ and ‘some’ dehydration indicated moderate congruence between virtual and in-person examinations (0.69; 95% CI: 0.41 to 0.98). At 10 days, 273 (95%) of the 287 cases reached by phone were better/recovered.ConclusionCritical components of the virtual examination (triage, danger signs and dehydration assessment) performed well despite varied performance among the problem-specific components. The study and associated resources represents formative steps towards an evidence-based paediatric telemedicine guideline built on WHO clinical principles. In-person examinations for select cases were important to address limitations with virtual examinations and identify cases for escalation.Trial registration numberNCT03943654.

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Implementation of a Pediatric Telemedicine and Medication Delivery Service in a Resource-limited Setting: A Pilot Study for Clinical Safety and Feasibility

Cited by 5 publications

References 26 publications

Development and Evaluation of a Clinical Guideline for a Pediatric Telemedicine and Medication Delivery Service: A Prospective Cohort Study in Haiti

Development and Evaluation of a Clinical Guideline for a Pediatric Telemedicine and Medication Delivery Service: A Prospective Cohort Study in Haiti

Evaluating the prerequisites for adapting a paediatric nighttime telemedicine and medication delivery service to a setting with high malarial burden: A cross‐sectional pre‐implementation study

Development and evaluation of a clinical guideline for a paediatric telemedicine service in a low-resource setting

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