Risk Stratification of Fetal Cardiac Anomalies in an Underserved Population Using Telecardiology

Abstract

OBJECTIVE: To evaluate a fetal telecardiology program in a medically underserved area. METHODS: We conducted a prospective case series of pregnant women at 18–38 weeks of gestation with risk factors for fetal congenital heart disease. Obstetric ultrasonographers performed fetal echocardiograms (local site) that were read in real time. The results were given to the mother by a fetal cardiologist at a children's hospital 243 miles and two mountain passes away (distant site). We evaluated the fetal telecardiology program in five domains: 1) education of obstetric ultrasonographers before initiation of telecardiology services, 2) process and efficiency, 3) patient satisfaction, 4) economic effects, and 5) accuracy of cardiac diagnosis and success of risk stratification. RESULTS: The program was initiated on November 12, 2015, and here we describe its first 37 months. Over the initial training period of 3 months and about 70 examinations, obstetric ultrasonographers improved their identification of fetal congenital heart disease. Telecardiology was performed once a week and also for suspected fetal congenital heart disease or arrhythmia outside clinic hours, for a total of 455 examinations. All mothers preferred having their fetal cardiac evaluations performed locally as opposed to traveling to the distant center. The estimated cost to parents for fetal cardiac evaluation at the distant center was nine times greater than that of telecardiology ($581 vs $61). Congenital heart disease or arrhythmia was diagnosed in 28 and 15 fetuses, respectively; there was one false-negative result. All fetuses were correctly risk-stratified with respect to delivery location. CONCLUSIONS: Neither diagnostic quality nor patient satisfaction were sacrificed with telecardiology. The program was feasible, empowered the local health care providers and ultrasonographers, offered strong economic advantages to families, and offered the benefit of timely standard-of-care, face-to-face consultation without travel. Based on the success of this program, further studies are warranted to assess its replicability.

Improving Access to Care: Telemedicine Across Medical Domains

“…Multiple studies have evaluated the use of video calls in rural areas to aid in fetal cardiac evaluations and also to connect regional specialists with local providers to give guidance on necessary procedures. Both applications have demonstrated decreased travel time and costs, with some studies citing up to a ninefold decrease in expenditures for pregnant individuals in rural settings, with no evidence of harm or decrease in quality of care (24,44). More recent evolving applications of telemedicine within obstetrics involve the use of remote monitoring devices.…”

<p>Review of Health Economics of Point-of-Care Testing Worldwide and Its Efficacy of Implementation in the Primary Health Care Setting in Remote Australia</p>

“…For example, use of telecardiology showed that all foetuses with congenital heart disease (CHD) were correctly risk-stratified for delivery. 9 The cost of POCUS is a major economic aspect in developing countries as it is deemed suitable only if leading to similar outcomes but with lower expenses as compared to current obstetric examination. 10 Therefore, training and application of POCUS have to reflect the needs of the specific communities and must be tailored accordingly.…”

Virtual Care Across the Neonatal Intensive Care Continuum

“…The initial use involved transmitting ultrasound images via the nascent internet to obtain a second expert opinion regarding concern for fetal anatomic anomaly [1]. Since then, many have used telemedicine visits to provide consultation to those in a rural setting far removed from tertiary care with positive outcomes and patient satisfaction [2][3][4]. This modality of providing care did not reach general consciousness until 2020 due to the coronavirus disease 2019 (COVID-19) pandemic.…”