Outcomes Associated With Rural Emergency Department Provider-to-Provider Telehealth for Sepsis Care: A Multicenter Cohort Study

Mohr, Nicholas M.; Okoro, Uche; Harland, Karisa; Fuller, Brian M.; Campbell, Kalyn; Wymore, Cole; Faine, Brett; Zepeski, Anne; Parker, Edith A.; Mack, Luke; Bell, Amanda; DeJong, Katie; Mueller, Keith J.; Chrischilles, Elizabeth A.; Wallace, Kelli; Jones, Michael P.; Ward, Marcia M.

doi:10.1016/j.annemergmed.2022.07.024

Cited by 6 publications

(5 citation statements)

References 59 publications

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“…In this qualitative follow-up to the original TELEVISED quantitative analysis 24 , we found that telehealth was used most frequently-and was perceived to have the greatest valuein very discrete clinical scenarios. Patients requiring interhospital transfer, those treated by less experienced providers or who had regulatory requirement-mandated supervision were those for whom tele-ED was used most often.…”

Section: Discussionmentioning

confidence: 90%

“…23 In another multicenter study in telehealth-capable hospitals with contemporary controls (n=1,191), we found telehealth consultation was not associated with improved outcomes, but the subgroup of patients treated in the most remote hospitals by advanced practice providers may have had reduced mortality (aOR 0.11, 95% CI 0.02 to 0.73). 24 Since these findings were unexpected, we conducted a qualitative study of rural hospital and hub healthcare staff to better understand and interpret the findings from our quantitative studies.…”

Section: Importancementioning

confidence: 99%

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The Role of Sepsis Care in Rural Emergency Departments: A Qualitative Study of Emergency Department User Perspectives

Mohr,

Merchant,

Fuller

et al. 2024

Preprint

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Objective: Sepsis is a leading cause of hospitalization and death in the United States, and rural patients are at particularly high risk. Telehealth has been proposed as one strategy to narrow rural-urban disparities. The objective of this study was to understand why staff use provider-to-provider telehealth in rural emergency departments (tele-ED) and how tele-ED care changes the care for rural patients with sepsis. Methods: We conducted a qualitative interview study between March 1, 2022 and May 22, 2023 with participants from upper Midwest rural EDs the tele-ED hub physicians in a single tele-ED network that delivers provider-to-provider consultation for sepsis patients. One interviewer conducted individual telephone interviews, then we used standard qualitative methods based on modified grounded theory to identify themes and domains. Results: We interviewed 27 participants, and from the interviews we identified nine themes within three domains. Participants largely felt tele-ED for sepsis was valuable in their practice. We identified that telehealth was consulted to facilitate interhospital transfer, provide surge capacity for small teams, to adhere with policy around provider scope of practice, for inexperienced providers, and for patients with increased severity of illness or complex comorbidities. Barriers to tele-ED use and impact of tele-ED included increased sepsis care standardization, provider reluctance, and sepsis diagnostic uncertainty. Additionally, we identified that real-time education and training were important secondary benefits identified from tele-ED use. Conclusions: Tele-ED care was used by rural providers for sepsis treatment, but many barriers existed that may have limited potential benefits to its use.

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Section: Discussionmentioning

confidence: 90%

Section: Importancementioning

confidence: 99%

The Role of Sepsis Care in Rural Emergency Departments: A Qualitative Study of Emergency Department User Perspectives

Mohr,

Merchant,

Fuller

et al. 2024

Preprint

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“…were similar in sepsis patients that used tele-ED compared with sepsis patients in the same hospitals that did not. 28 Rural sepsis patients commonly seek care in their local community, and both rural hospital bypass and interhospital transfer have been associated with increased mortality. 4,38,39 These findings suggest that delays in appropriate high-quality care for rural patients may drive poor outcomes, and that optimal early care delivered in rural communities may be one of the few strategies available to reduce sepsis outcome disparities.…”

Section: Discussionmentioning

confidence: 99%

“…These current results align with the overall findings of the TELEVISED study, which was conducted in a small sample of tele‐ED–capable hospitals and showed that risk‐adjusted 28‐day hospital‐free days (difference 0.07 days, 95% CI −0.04 to 0.17 days) and 28‐day mortality (aOR 0.51, 95% CI 0.16–1.60) were similar in sepsis patients that used tele‐ED compared with sepsis patients in the same hospitals that did not 28 . Rural sepsis patients commonly seek care in their local community, and both rural hospital bypass and interhospital transfer have been associated with increased mortality 4,38,39 .…”

Section: Discussionmentioning

confidence: 99%

“…In the patient‐level analysis, our exposure was treatment using tele‐ED, compared with a propensity‐matched control group of similar sepsis patients treated in non–tele‐ED–capable hospitals. We conducted both analyses for two reasons (1) non–tele‐ED patients treated in tele‐ED–capable hospitals have previously been shown to have care that is similar to care provided to tele‐ED patients (contamination in the care of non–tele‐ED patients) 26,27 and (2) patients who have tele‐ED use typically have greater illness severity 26,28 . Medicare administrative claims do not have a high‐quality physiologic severity of illness measure (confounding bias), so hospital‐level analysis was our primary analysis because it was less subject to confounding by indication.…”

Section: Methodsmentioning

confidence: 99%

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Provider‐to‐provider telehealth for sepsis patients in a cohort of rural emergency departments

Mohr,

Young,

Vakkalanka

et al. 2024

Academic Emergency Medicine

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BackgroundTelehealth has been proposed as one strategy to improve the quality of time‐sensitive sepsis care in rural emergency departments (EDs). The purpose of this study was to measure the association between telehealth‐supplemented ED (tele‐ED) care, healthcare costs, and clinical outcomes among patients with sepsis in rural EDs.MethodsCohort study using Medicare fee‐for‐service claims data for beneficiaries treated for sepsis in rural EDs between February 1, 2017 and September 30, 2019. Our primary hospital‐level analysis used multivariable generalized estimating equations (GEE) to measure the association between treatment in a tele‐ED‐capable hospital and 30‐day total costs of care. In our supporting secondary analysis, we conducted a propensity‐matched analysis of patients who used tele‐ED with matched controls from non‐tele‐ED‐capable hospitals. Our primary outcome was total healthcare payments among index hospitalized patients between the index ED visit and 30 days after hospital discharge, and our secondary outcomes included hospital mortality, hospital length‐of‐stay, 90‐day mortality, 28‐day hospital‐free‐days, and 30‐day inpatient readmissions.ResultsIn our primary analysis, sepsis patients in tele‐ED‐capable hospitals had 6.7% higher (95% CI 2.1 to 11.5%) total healthcare costs compared to those in non‐tele‐ED‐capable hospitals. In our propensity‐matched patient‐level analysis, total healthcare costs were 23% higher (95% CI 16.5 to 30.4%) in tele‐ED cases than matched non‐tele‐ED controls. Clinical outcomes were similar.ConclusionTele‐ED capability in a mature rural tele‐ED network was not associated with decreased healthcare costs or improved clinical outcomes. Future work is needed to reduce rural‐urban sepsis care disparities and formalize systems of regionalized care.

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The effect of sepsis recognition on telemedicine use and bundle completion in rural emergency department sepsis treatment

Vakkalanka

Okoro

Wymore

et al. 2023

Preprint

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Objective: Sepsis has high mortality, but it is often not recognized due to varied and vague presentations. Provider-to-provider emergency department telehealth (tele-ED) has been proposed to improve rural sepsis care, but we hypothesized that its use and effectiveness is dependent on local sepsis recognition. The objective of this study was to measure the association between sepsis documentation and tele-ED use, treatment guideline adherence, and mortality. Methods: This analysis was a multicenter (n=23) cohort study of sepsis patients treated in rural emergency departments (EDs) that participated in a tele-ED network between August 2016 and June 2019. The primary exposure was whether sepsis was recognized in the local ED, and the primary outcome was rural tele-ED use, with secondary outcomes of time to tele-ED use, 3-hour guideline adherence, and in-hospital mortality. We used multivariable generalized estimating equation models for our analysis. Results: Data from 1,146 rural sepsis patients were included, 315 (27%) had tele-ED used, and 415 (36%) had sepsis recognized in the rural ED. Sepsis recognition was not independently associated with higher rates of tele-ED use (adjusted odds ratio [aOR] 1.23, 95% CI 0.90-1.67). Sepsis recognition was associated with earlier tele-ED activation (adjusted hazard ratio [aHR] 1.69, 95% CI 1.34-2.13), lower 3-hour guideline adherence (aOR 0.73, 95% CI: 0.55-0.97), and lower in-hospital mortality (aOR 0.72, 95% CI: 0.54-0.97). Conclusions: Sepsis recognition in rural EDs participating in a tele-ED network was not associated with tele-ED use. Future work will focus on how telehealth can be used to improve diagnostic accuracy and sepsis recognition.

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Outcomes Associated With Rural Emergency Department Provider-to-Provider Telehealth for Sepsis Care: A Multicenter Cohort Study

Cited by 6 publications

References 59 publications

The Role of Sepsis Care in Rural Emergency Departments: A Qualitative Study of Emergency Department User Perspectives

The Role of Sepsis Care in Rural Emergency Departments: A Qualitative Study of Emergency Department User Perspectives

Provider‐to‐provider telehealth for sepsis patients in a cohort of rural emergency departments

The effect of sepsis recognition on telemedicine use and bundle completion in rural emergency department sepsis treatment

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