Andersons pediatric cardiology 2309
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available.Managementdecisionsbasedonincompleteordelayeddiagnostic
informationmayresultinmorbidityandmortalityorunnecessarytransfers.
Randolphetal.reportedthatusingtelemedicineresultedinacompletediagnosis
for132of133patients(99%)withsuspectedcongenitalheartdisease.Patient
transferwasrecommendedoravoidedinsevenpatients,animmediatechangein
localmedicalmanagementoccurredinanadditional25of133neonatalpatients
(19%),andcongenitalheartdiseasenotrequiringimmediatetreatmentwasnoted
in47infants(35%).17
Table91.1
HistoryofPediatric/CongenitalTele-EchocardiographyPublications
Study
Finley11,63,138
Sobczyk12
Fisher2,3
Casey15,139–141
Rendina18,19,142
Houston4
Randolph17
Sable6
Scholz14,143
Sable7
Sharma27
Widmer144
Munir145
Sahn146
Woodson8
Castela147
Lewin13
Awadallah16
Sekar148
Koustic107
Gomes62
McCrossan34,149
Location
Year(s)
NovaScotia 1989,
1997,
2004
Kentucky
1993
Chicago
1996
Ireland
1996,
1998,
2008
North
1997,
Carolina
1998
Glasgow
1999
Minnesota 1999
New
1999
Orleans
Iowa
1999,
2001
Washington, 2002
DC
NewYork 2003
Switzerland 2003
Hawaii
2004
Portland
2004
Washington, 2004
DC
Portugal
2005
Seattle
2006
South
2006
Dakota
India
2007
London
2007
Portugal
2010
Ireland
2011,
KeyFindings
RealtimeoverPOTS,costsavings,tele-education
StoreandforwardoverPOTS
RealtimeoversingleISDNline
Realtimeoverlowbandwidthconnection
Outcomesandreducedlengthofstay
100%accuracyrequires3ISDNlines
Accuracy,managementoverT1
Accuracy,proficiency,costsavingsover3ISDNlines
Minimaldifference:cardiologistvs.pediatricianorderingechoin
childrenlessthanoneyearofage
500studies/3ISDNlines/impactonpractice
Efficacyoffetaltele-echocardiography
Realtimeover3ISDNlines/feasibilityandaccuracy
LiveandstoreandforwardbetweenHawaiiandGuam
Remoterealtimeimagecontrolandoptimization
Forwardandstoretele-echocardiography
1761consultationsover5years/mostlyelective
769studies/3ISDNlines/99%accurate
Neonataltele-echocardiographytriage
Realtime/smallaperturesatellitebandwidth
BelgradetoLondonconferenceoversingleISDNline
Fetal,neonatal,andpediatricconsultationsinrealtime
Fetaltele-echoaccuracyandskilltransfer
Haley150
Dehghani151
Webb22
Krishan21
2012
Arizona
2012
Canada
2013
US(9sites) 2013
Washington, 2014
DC
Realtimetelemedicinemoreaccuratethanrecordedechocardiograms
VideoconferencingforACHDmanagement
Multicenterprospectivecase-controlstudy:tele-echodecreases
transports,lengthofstay,andhigh-riskmedications
Technologytransition,>10,000studies/15years
ACHD,Adultwithcongenitalheartdisease;ISDN,integratedservicesdigitalnetwork;POTS,plain
oldtelephonesystems;T1,Terrestrial1.
FromSatouGM,RheubanK,AlversonD,etal.Telemedicineinpediatriccardiology:ascientific
statementfromtheAmericanHeartAssociation.Circulation.2017;135(11):e648–e748.
Rendinaetal.reportedareductioninlengthofstayof5.4daysinalevelIII
NorthCarolinaneonatalintensivecareunitinthefirst6monthsoftheirstudy
comparedtothe6monthspriorwithouttelemedicine.18,19Thecostattributable
totelemedicineintheirmodelwas$33perechocardiogram.Theyprojectedthat
costsavingsovera1-yearperiodwouldbe$1.3million.Additionalmonetary
benefitsoftelemedicinethataremoredifficulttoquantifyincludecostsavings
frompreventionofdelayedorincorrectmanagement,andavoidanceofthe
financialburdenoftravelandlostwagesforthepatient'sfamily.20Inastudyof
500echocardiogramsintheWashington,DC,metroarea,comparisonoffinal
videotapeinterpretationtoinitialtelemedicinediagnosisresultedinonlyone
minordiagnosticchange(membranousvs.inletventricularseptaldefect),and
telemedicinehadanimmediateimpactonpatientcarein151studies.7
Wereportedonourtechnologytransitionexperienceofover10,000
telemedicinetransmissionsfrom24sitesinsevenstatesandterritoriesbetween
1998and2014.21Asignificantincreaseintelecardiologyutilizationtookplace
afterIPexpansionwithoutdetrimentaleffectsonefficiencyordiagnostic
accuracy.Thisoccurredinparalleltoachangefromapredominanceofreal-time
telemedicinetostoreandforwardtransmissions.Over150patientswere
transportedforsurgical,catheter-based,ormedicalintervention,andcritical
heartdiseasewasruledoutinover75patients,preventingunnecessarytransport.
Medicalmanagementand/oroutpatientfollow-upwasrecommendedin
approximatelyhalfofthestudiesforminorheartdefects.
Amulticenterstudyfromninecentersassessedtheimpactoftelemedicineon
infantswitheithernoorminorheartdisease.Theauthorsidentified338pairsof
infantswithandwithoutaccesstotelemedicine,andwerematchedforstudy
indication,diagnosis,gestationalage,birthweight,andgender.22Accessto
telemedicineresultedinstatisticallysignificantreductionsinrateoftransfertoa
tertiarycarehospital(10%vs.5%),totalandintensivecareunitlengthofstay,
andinappropriateuseofinotropicsupportandindomethacin(Tables91.2and
91.3).
Table91.2
LengthofStayFromaMulticenterStudy
Telemedicine
INCLUDINGOUTLIERSa
Totallengthofstay
LengthofICUstay
EXCLUDINGOUTLIERSa
Totallengthofstay
LengthofICUstay
Control
PValue
1.0±6.8days
Range:0–102days
0.96±6.8days
Range:0–102days
2.6±11days
Range:0–96days
2.5±11days
Range:0–96days
.005
0.72±4.1days
Range:0–44days
0.65±4.0days
Range:0–44days
1.6±6.4days
Range:0–58days
1.6±6.2days
Range:0–58days
.027
.024
.026
a
Greaterthan60days.
ICU,Intensivecareunit.
FromWebbCL,WaughCL,GrigsbyJ,etal.Impactoftelemedicineonhospitaltransport,length
ofstay,andmedicaloutcomesininfantswithsuspectedheartdisease:amulticenterstudy.JAm
SocEchocardiogr.2013;26(9):1090–1010.
Table91.3
MedicalComplications/InterventionsFromaMulticenterStudy
Inotropicsupport
Indomethacina
ProstaglandinE1
Mechanicalventilation
Extracorporealmembraneoxygenation
Intraventricularhemorrhage
Cardiacarrest
Death
Telemedicine
8%(n=27)
11%(n=29)
0%(n=0)
28%(n=94)
1%(n=2)
7%(n=24)
2%(n=6)
4%(n=13)
Control
26%(n=88)
18%(n=47)
<1%(n=1)
30%(n=101)
<1%(n=1)
5%(n=15)
3%(n=11)
4%(n=12)
PValue
<.001
.026
NS
NS
NS
NS
NS
NS
aIndomethacindataonlyavailableon268matchedpairs
FromWebbCL,WaughCL,GrigsbyJ,etal.Impactoftelemedicineonhospitaltransport,length
ofstay,andmedicaloutcomesininfantswithsuspectedheartdisease:amulticenterstudy.JAm
SocEchocardiogr.2013;26(9):1090–1098.
Neonatalpulseoximetryscreeningforcriticalcongenitalheartdiseaseis
