EAL

TN: Telenutrition Interventions by Registered Dietitians (2012)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

To examine management outcome of home parenteral nutrition (HPN) patients when followed by telehealth as an alternative modality of care with a survey.

Inclusion Criteria:

Referred to telehealth video-conferencing
Home parenteral nutrition patient and part of the HPN program
Unable to travel to Toronto General Hospital (TGH) due to cost, weather or distance.

Exclusion Criteria:

Not described.

Description of Study Protocol:

Recruitment

Patients were referred to telehealth video-conferencing when they were unable to travel to TGH due to cost, weather or distance
The HPN nurse clinician requested consultations through the UHN telehealth department
The online consultation request form includes contact information, diagnosis, distant-site care providers and physical assessment data to be completed before the scheduled sessions.

Design

Before and after study.

Blinding Used

Implied with measurements.

Intervention

30-minute telehealth session.

Statistical Analysis

Cost analysis of telehealth infrastructure, which was based on three items: Technology, human resources and infrastructure
Satisfaction survey, which included ordinal scale responses (always, usually, sometimes and never).

Data Collection Summary:

Timing of Measurements

Measurements made before and after telehealth sessions.

Dependent Variables

Line sepsis rate: Measured by a survey question that focused on catheter complication within the past three years of telehealth. Patients were also asked about other complications related to HPN medical management such as central line replacements, dehydrations and physician visits related to HPN.
Cost analysis of telehealth consultation, based on technology, human resources and infrastructure: For human resources, the salaries of the telehealth technician and administration staff of the remote site were considered, as well as the salaries of the multi-disciplinary staff (nurse, dietitian and pharmacist).

Independent Variables

Telehealth satisfaction: Assessed using a 10-item data collection form during telehealth sessions, which provided information on the type of consultation, data about the distant site, family or caregiver presence, data about our base site, the time it took for each member to interact with the patient, the types of assessment including review of patient history from the last visit, discussion of results and treatment options
Patient assessment: Including inspection and examination over interactive video using a digital camera
Nutrition support team completes the parenteral nutrition (PN) clinic flow sheet and the physician summarizes the session, which includes the treatment plan to be integrated in the ambulatory patient chart before leaving the video-conference session
Patient satisfaction survey: Completed by patients by mail. The survey consisted of 18 questions that used the Likert scale to evaluate whether or not the patient was able to talk with the PN team about their most important concerns and if they were involved with care as much as possible.

Description of Actual Data Sample:

Initial N: 21 subjects receiving telehealth, but only 13 subjects eligible to receive survey
Attrition (final N): 13 subjects (nine women, four men)
Age: 24 years to 75 years
Ethnicity: Not described
Other relevant demographics: Not reported
Anthropometrics: Not reported
Location: Toronto, Ontario, Canada.

Summary of Results:

Key Findings

The satisfaction survey response rate was impressive, with a return rate of 11 out of 13 (84.6%)
All patients were generally satisfied with video-conferencing as an alternative method of communication and care for new consultation, patient and family education and follow-up
The average line sepsis rate for the 13 patients was 0.89 per 1,000 catheter-days.

Other Findings

Travel time and costs to the patients, their families and the health care system were significantly less, since a patient residing 611km away would spend $724 Canadian for a flight and accommodations to meet with the healthcare team in Toronto
The estimated cost of a telehealth consultation for a home parenteral nutrition patient in 2005 was $203.66 Canadian per session.

Author Conclusion:

This study suggests that telehealth lowered costs to both the rural patient and health care system, while providing increased satisfaction
Overall, the effect of telehealth in HPN deserves further consideration for a national application.

Funding Source:

University/Hospital:

Toronto General Hospital, University of Toronto Division of Gastroenterology, Department of Medicine

Reviewer Comments:

The authors acknowledge a small sample size, but found no increase in line sepsis rates with these patients, compared with evidence-based literature studies defining line sepsis rates of 1.2 per 1,000 catheter-days.

Quality Criteria Checklist: Primary Research
Relevance Questions
	1.	Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)	Yes
	2.	Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?	Yes
	3.	Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?	Yes
	4.	Is the intervention or procedure feasible? (NA for some epidemiological studies)	Yes

Validity Questions
1.	Was the research question clearly stated?		Yes
	1.1.	Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?	Yes
	1.2.	Was (were) the outcome(s) [dependent variable(s)] clearly indicated?	Yes
	1.3.	Were the target population and setting specified?	Yes
2.	Was the selection of study subjects/patients free from bias?		No
	2.1.	Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?	No
	2.2.	Were criteria applied equally to all study groups?	Yes
	2.3.	Were health, demographics, and other characteristics of subjects described?	No
	2.4.	Were the subjects/patients a representative sample of the relevant population?	No
3.	Were study groups comparable?		N/A
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	N/A
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	N/A
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	N/A
	3.4.	If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?	N/A
	3.5.	If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)	N/A
	3.6.	If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?	N/A
4.	Was method of handling withdrawals described?		Yes
	4.1.	Were follow-up methods described and the same for all groups?	Yes
	4.2.	Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)	Yes
	4.3.	Were all enrolled subjects/patients (in the original sample) accounted for?	Yes
	4.4.	Were reasons for withdrawals similar across groups?	N/A
	4.5.	If diagnostic test, was decision to perform reference test not dependent on results of test under study?	N/A
5.	Was blinding used to prevent introduction of bias?		Yes
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	No
	5.2.	Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)	Yes
	5.3.	In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?	N/A
	5.4.	In case control study, was case definition explicit and case ascertainment not influenced by exposure status?	N/A
	5.5.	In diagnostic study, were test results blinded to patient history and other test results?	N/A
6.	Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?		Yes
	6.1.	In RCT or other intervention trial, were protocols described for all regimens studied?	Yes
	6.2.	In observational study, were interventions, study settings, and clinicians/provider described?	N/A
	6.3.	Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?	Yes
	6.4.	Was the amount of exposure and, if relevant, subject/patient compliance measured?	Yes
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	Yes
	6.6.	Were extra or unplanned treatments described?	Yes
	6.7.	Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?	Yes
	6.8.	In diagnostic study, were details of test administration and replication sufficient?	N/A
7.	Were outcomes clearly defined and the measurements valid and reliable?		Yes
	7.1.	Were primary and secondary endpoints described and relevant to the question?	Yes
	7.2.	Were nutrition measures appropriate to question and outcomes of concern?	Yes
	7.3.	Was the period of follow-up long enough for important outcome(s) to occur?	Yes
	7.4.	Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?	Yes
	7.5.	Was the measurement of effect at an appropriate level of precision?	Yes
	7.6.	Were other factors accounted for (measured) that could affect outcomes?	Yes
	7.7.	Were the measurements conducted consistently across groups?	Yes
8.	Was the statistical analysis appropriate for the study design and type of outcome indicators?		No
	8.1.	Were statistical analyses adequately described and the results reported appropriately?	No
	8.2.	Were correct statistical tests used and assumptions of test not violated?	N/A
	8.3.	Were statistics reported with levels of significance and/or confidence intervals?	No
	8.4.	Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?	N/A
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	No
	8.6.	Was clinical significance as well as statistical significance reported?	Yes
	8.7.	If negative findings, was a power calculation reported to address type 2 error?	No
9.	Are conclusions supported by results with biases and limitations taken into consideration?		Yes
	9.1.	Is there a discussion of findings?	Yes
	9.2.	Are biases and study limitations identified and discussed?	Yes
10.	Is bias due to study's funding or sponsorship unlikely?		Yes
	10.1.	Were sources of funding and investigators' affiliations described?	Yes
	10.2.	Was the study free from apparent conflict of interest?	Yes