There is increasing interest for patient-to-provider telemedicine in pediatric acute care. The suitability of telemedicine (virtualizability) for visits in this setting has not been formally assessed. We estimated the proportion of in-person pediatric emergency department (PED) visits that were potentially virtualizable, and identified factors associated with virtualizable care.
Methods
This was a retrospective analysis of in-person visits at the PED of a Canadian tertiary pediatric hospital (02/2018–12/2019). Three definitions of virtualizable care were developed: (1) a definition based on “resource use” classifying visits as virtualizable if they resulted in a home discharge, no diagnostic testing, and no return visit within 72 h; (2) a “diagnostic definition” based on primary ED diagnosis; and (3) a stringent “combined definition” by which visits were classified as virtualizable if they met both the resource use and diagnostic definitions. Multivariable logistic regression was used to identify factors associated with telemedicine suitability.
Results
There were 130,535 eligible visits from 80,727 individual patients during the study period. Using the most stringent combined definition of telemedicine suitability, 37.9% (95% confidence interval (CI) 37.6%–38.2%) of in-person visits were virtualizable. Overnight visits (adjusted odds ratio (aOR) 1.16–1.37), non-Canadian citizenship (aOR 1.10–1.18), ethnocultural vulnerability (aOR 1.14–1.22), and a consultation for head trauma (aOR 3.50–4.60) were associated with higher telemedicine suitability across definitions.
Discussion
There is a high potential for patient-to-provider telemedicine in the PED setting. Local patient and visit-level characteristics must be considered in the design of safe and inclusive telemedicine models for pediatric acute care.
MarcinJPRimszaMEMoskowitzWB and Committee on Pediatric W. The use of telemedicine to address access and physician workforce shortages. Pediatrics2015; 136: 202–209.
3.
SasangoharFDavisEKashBA,et al.Remote patient monitoring and telemedicine in neonatal and pediatric settings: Scoping literature review. J Med Internet Res2018; 20: e295.
4.
NadarMJouvetPTucciM,et al.Impact of synchronous telemedicine models on clinical outcomes in pediatric acute care settings: A systematic review. Pediatr Crit Care Med2018; 19: e662–ee71.
5.
ShahACBadawySM. Telemedicine in pediatrics: Systematic review of randomized controlled trials. JMIR Pediatr Parent2021; 4: e22696.
6.
FinkelsteinYMaguireBZemekR, et al.Effect of the COVID-19 pandemic on patient volumes, acuity, and outcomes in pediatric emergency departments: A Nationwide study. Pediatr Emerg Care2021; 37: 427–434.
7.
HartnettKKite-PowellADeViesJ, et al.Impact of the COVID-19 pandemic on emergency department visits – United States, January 1, 2019–May 30, 2020.; 2020 ePub: 3 June 2020.
8.
YamamotoLG. Access to optimal emergency care for children. Pediatrics2007; 119: 161–164.
9.
GattuRTeshomeGLichensteinR. Telemedicine applications for the pediatric emergency medicine: A review of the current literature. Pediatr Emerg Care2016; 32: 123–130.
10.
KimJWTiyyaguraGLanghanM. A qualitative analysis of general emergency medicine Providers’ perceptions on pediatric emergency telemedicine. Pediatr Emerg Care2019; 35: 856–861.
11.
Uscher-PinesLKahnJM. Barriers and facilitators to pediatric emergency telemedicine in the United States. Telemed J E Health2014; 20: 990–996.
12.
McConnochieKMWoodNEHerendeenNE,et al.Telemedicine in urban and suburban childcare and elementary schools lightens family burdens. Telemed J E Health2010; 16: 533–542.
13.
VyasSMurren-BoezemJSolo-JosephsonP. Analysis of a Pediatric Telemedicine Program. Telemed J E Health2018; 24. (online). Available from https://doi.org/10.1089/tmj.2017.0281.
14.
McConnochieKMConnersGPBrayerAF, et al.Effectiveness of telemedicine in replacing in-person evaluation for acute childhood illness in office settings. Telemed J E Health2006; 12: 308–316.
15.
RayKNShiZPoonSJ,et al.Use of commercial direct-to-consumer telemedicine by children. Acad Pediatr2019; 19: 665–669.
16.
Institute Of Medicine. IOM Report: The future of emergency care in the United States health system. Acad Emerg Med2006; 13: 1081–1085.
17.
DoanQGenuisEDYuA. Trends in use in a Canadian pediatric emergency department. CJEM2014; 16: 405–410.
18.
StangASMcGillivrayDBhattM, et al.Markers of overcrowding in a pediatric emergency department. Acad Emerg Med2010; 17: 151–156.
19.
FarionKJWrightMZemekR, et al.Understanding low-acuity visits to the pediatric emergency department. PLoS One2015; 10: e0128927.
20.
LongCMMehrhoffCAbdel-LatiefE,et al.Factors influencing pediatric emergency department visits for low-acuity conditions. Pediatr Emerg Care2018; 37: 265–268.
21.
OsmanlliuEGagnonIWeberS,et al.The WAVE pathway (Waiting Room Assessment to Virtual Emergency): Initiating video-based telemedicine in the pediatric emergency department. J Telemed Telecare2021; 28: 452–457.
22.
RosenfieldDMcLeanLClemensJ,et al.Opening the digital front door: Digital offerings in a pediatric emergency department. Can J Emergency Med2021; 23: 857.
23.
ReidSBhattMZemekR,et al.Virtual care in the pediatric emergency department: A new way of doing business?Can J Emergency Med2021; 23: 80–84.
24.
MohrNMHarlandKKShaneDM,et al.Potentially avoidable pediatric interfacility transfer is a costly burden for rural families: A cohort study. Acad Emerg Med2016; 23: 885–894.
25.
RosenthalJLLiengMKMarcinJP,et al.Profiling pediatric potentially avoidable transfers using procedure and diagnosis codes. Pediatr Emerg Care2021; 37: e750–e7e6.
26.
PeeblesERMillerMRLynchTP,et al.Factors associated with discharge home after transfer to a pediatric emergency department. Pediatr Emerg Care2018; 34: 650–655.
27.
LiJMonuteauxMCBachurRG. Interfacility transfers of noncritically ill children to academic pediatric emergency departments. Pediatrics2012; 130: 83–92.
28.
CurfmanAGroenendykJMarkhamC, et al.Implementation of telemedicine in pediatric and neonatal transport. Air Med J2020; 39: 271–275.
29.
CollinsGSReitsmaJBAltmanDG,et al.Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): The TRIPOD statement. Eur Urol2015; 67: 1142–1151.
Statistics Canada. The Canadian Index of Multiple Deprivation. 2019. Report No.: 45-20-0001.
32.
MurrayMJ. The Canadian triage and acuity scale: A Canadian perspective on emergency department triage. Emerg Med (N Y)2003; 15: 6–10.
33.
McCoolRRDaviesL. Where does telemedicine fit into otolaryngology? An assessment of telemedicine eligibility among otolaryngology diagnoses. Otolaryngol Head Neck Surg2018; 158: 641–644.
34.
LeeJIsraelEWeinsteinH, et al.Using physician-level emergency department utilization reports to address avoidable visits by patients managed by pediatric specialists. Hosp Pediatr2017; 7: 686–691.
35.
HsiaRYNiedzwieckiM. Avoidable emergency department visits: A starting point. Int J Qual Health Care2017; 29: 642–645.
36.
WeinickRMBurnsRMMehrotraA. Many emergency department visits could be managed at urgent care centers and retail clinics. Health Aff (Millwood)2010; 29: 1630–1636.
37.
FieldstonESAlpernERNadelFM,et al.A qualitative assessment of reasons for nonurgent visits to the emergency department: Parent and health professional opinions. Pediatr Emerg Care2012; 28: 220–225.
38.
BrousseauDCNimmerMRYunkNL,et al.Nonurgent emergency-department care: Analysis of parent and primary physician perspectives. Pediatrics2011; 127: e375–e381.
39.
DavisTMeyerABesteJ,et al.Decreasing low acuity pediatric emergency room visits with increased clinic access and improved parent education. J Am Board Fam Med2018; 31: 550–557.
40.
RuiPKangKAshmanJJ. National Hospital Ambulatory Medical Care Survey: 2016 Emergency department summary tables. Centers for Disease Control and Prevention, 2016.
41.
DoobininKAHeidt-DavisPEGrossTK,et al.Nonurgent pediatric emergency department visits: Care-seeking behavior and parental knowledge of insurance. Pediatr Emerg Care2003; 19: 10–14.
42.
RaviNGitzKMBurtonDR,et al.Pediatric non-urgent emergency department visits and prior care-seeking at primary care. BMC Health Serv Res2021; 21: 466.
HsiaRYFriedmanABNiedzwieckiM. Urgent care needs among nonurgent visits to the emergency department. JAMA Intern Med2016; 176: 852–854.
45.
BrandenbergerJBozorgmehrKVogtF,et al.Preventable admissions and emergency-department-visits in pediatric asylum-seeking and non-asylum-seeking patients. Int J Equity Health2020; 19: 58.
46.
BregsteinJFensterDLameM. Pediatric emergency telemedicine: An untapped resource for vulnerable populations during COVID-19. Pediatr Emerg Care2021; 37: 230–231.
47.
RustGYeJBaltrusP,et al.Practical barriers to timely primary care access: Impact on adult use of emergency department services. Arch Intern Med2008; 168: 1705–1710.
48.
RobertsETMehrotraA. Assessment of disparities in digital access among medicare beneficiaries and implications for telemedicine. JAMA Intern Med2020; 180: 1386–1389.
49.
ThronsonLRJacksonSLChewLD. The pandemic of health care inequity. JAMA Network Open2020; 3: e2021767.
50.
OsmanlliuEJohariRScheinkerD. Health and healthcare disparities associated with the digital divide. Annals of Family Medicine, COVID-19 Collection. 2021; Pre-print.
51.
AsadaYKephartG. Equity in health services use and intensity of use in Canada. BMC Health Serv Res2007; 7: 41.
52.
KhoongENouriSLylesC,et al.Addressing equity in telemedicine for chronic disease management during the Covid-19 pandemic. NEJM Catal Innov Care Deliv2020; 20: 1–13.
53.
CurfmanALHackellJMHerendeenNE, et al.Telehealth: Improving access to and quality of pediatric health care. Pediatrics2021; 148: e2021053129.
54.
MannixRBazarianJJ. Managing pediatric concussion in the emergency department. Ann Emerg Med2020; 75: 762–766.
55.
MeHEChandraSSNasrallahFA. Deep neural networks predict the need for CT in pediatric mild traumatic brain injury: A corroboration of the PECARN rule. J Am Coll Radiol2022; 19: 769–778.
56.
CaiYZhengYJGulatiA, et al.Patient use of low-cost digital videoscopes and smartphones for remote ear and oropharyngeal examinations. JAMA Otolaryngol Head Neck Surg2021; 147: 336–342.
57.
KuppermannNDayanPSLevineDA, et al.A clinical prediction rule to identify febrile infants 60 days and younger at low risk for serious bacterial infections. JAMA Pediatr2019; 173: 342–351.
SoonSSvavarsdottirHDowneyC,et al.Wearable devices for remote vital signs monitoring in the outpatient setting: An overview of the field. BMJ Innov2020; 6: 55–71.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
