Service to Improve Healthcare in Rural Areas Essay Example

is important for three reasons: Firstly, GPs ensure appropriate care by maximizing individual health benefits with limited resources, especially for elderly and chronically-ill patients. Secondly, primary care helps control costs by providing effective actions to prevent unnecessary hospital visits and reduce waiting periods.

It is the responsibility of GPs to ensure that patients have optimal access to care, especially for those residing in remote rural areas who face logistical challenges when accessing secondary care due to distance, transportation costs and delayed treatment. The difficulty in accessing healthcare services in rural regions has resulted in higher disease and mortality rates, often leading to population migration from rural areas into urban centers. As a result, innovative organizational strategies are necessary to improve intervention effectiveness and timeliness while enhancing the connection between primary and secondary care.

Telemedicine (TM) involves utilizing electronic information communication technologies (ICT) to provide healthcare (HC) from a distance. This innovative solution is highly regarded by medical professionals and citizens alike, especially when it comes to enhancing access in remote locations. One essential application of TM for primary care is teleconsultation, which allows general practitioners (GPs) to receive specialist consultation. Research has indicated that teleconsultation services for GPs are feasible, effective, and have the potential to decrease expenses, enhance organizational efficiency and increase patient satisfaction. However, there is a necessity for more comprehensive evaluation of teleconsultation services covering various aspects such as HCS accessibility, acceptance levels, organizational impact, usefulness, effectiveness and economic viability of the service. Consequently, this study aims to conduct a comprehensive assessment on the impact of teleconsultation services utilized by GPs in rural areas.

------------------------------------------------- This section gives a description of the methods used in

the TELEMACO Project. The Ethics Committee of Local Health Authority of Valle Camonica was informed about the protocol on May 15th, 2007. Prior to this, on July 8th, 2004, a communication about Teleconsultation Second Opinion was also given to the Ethics Regional Committee of Lombardy within the SUMMA project [21]. Informed consent was obtained from all patients, and the study was conducted in line with the principles outlined in the Declaration of Helsinki.

The present investigation into teleconsultation services for GPs is part of the TELEMACO Project, which incorporates three other TM programs. The TELEMACO Project [33] was initiated by the Lombardy Region - Health Care Directorate in Italy and funded by the Italian Ministry of Health and the Italian Ministry of Innovation and Technologies. It has two objectives: to assist small rural communities in mountain valleys, where there are socioeconomic and infrastructural problems leading to migration from rural to urban areas, and to resolve the difficulties encountered in obtaining secondary care in those areas. In Italy, many visits to Emergency Departments (EDs) and hospitals are avoidable.

The TELEMACO Project seeks to lessen waiting lists by creating telemedicine networks that are multidisciplinary and cooperative, involving different entities like governments, local healthcare providers, specialized hospitals, small and rural hospitals, and General Practitioners (GPs). The project consists of four programs: teleconsultation for GPs; telemonitoring for post-hospital-discharge patients with Chronic Heart Failure (CHF) or Chronic Obstructive Pulmonary Disease (COPD); teleconsultation on digital images between rural hospitals and specialized hospitals for Traumatic Brain Injury (TBI) and Stroke; and cardiology emergency services using telemedicine in ambulances. In the Lombardy Region of Italy, GPs working in small communities were encouraged

to participate in the program through utilizing specialist-provided teleconsultation services in dermatology, cardiology, pneumology, and diabetology. However, not every enrolled GP used the offered service resulting in a classification into users and non-users.

The process of accessing teleconsultations for general practitioners (GPs) was structured in the following manner. In situations where a patient presented with ambiguous medical issues either at the GP's office or home, the GP could request a teleconsultation. During this consultation, the GP would provide the hospital specialist with the patient's health records and convey information regarding observed physical indicators and reported symptoms. The teleconsultation itself would take place via telephone between the GP and patient at the clinic, and the specialist at the hospital. Additionally, GPs were encouraged to use biomedical instruments for specific teleconsultations. Portable ECG recording devices were supplied to GPs for cardiac-related cases so that remote transmission could be done via an analog phone line. On the other hand, for dermatological cases, digital images (one with a close-up of the lesion and another for an overview of the affected area) were to be taken with a digital camera and sent through email.

The provision of teleconsultation was backed by an external Service Centre (SC) as discussed elsewhere [19]. In essence, the SC operators receive the GP's request, save the transmitted information on a specific database, connect the GP to a specialist on call and document the results of the teleconsultation. The assessment model of TM has various uses, however, the scientific community remains divided on its efficacy [34] as its benefits are yet to be shown [35]. In addition to demonstrating its effectiveness, there is a focus on a

holistic approach towards TM evaluation [36], and several stringent frameworks have been proposed for evaluating TM applications [37-39].

A multidimensional assessment has been conducted to comprehensively evaluate the TM service (TMS) based on various models. The assessment covers dimensions such as Access, which is primarily measured by the actual utilization of TM as suggested by the Institute of Medicine (IOM) [40] and other reviews [41]. The number of GPs and patients who have utilized and benefited from TMS in the project districts was used to measure access. In HC, access can also refer to availability, accessibility, accommodation, affordability and acceptability, which depict the fit between the patient and the system [42,43].

For the purpose of this project, geographic accessibility was assessed by considering the size of the communities from where General Practitioners (GPs) receive their patients. Moreover, their distance and time of travel from these communities to the nearest Healthcare (HC) providers were calculated, including those that offer visitations, examinations, hospitalizations, or admittance to emergency departments (EDs). The presumptive situation is that patients would avail themselves of the closest facilities. (ii) For a thorough evaluation of acceptance, a questionnaire was exclusively furnished to the GPs who were users of this project at its completion.

A 10-question questionnaire was utilized to evaluate the service. The assessment covered overall quality, contact with SC, clinical website, consultation quality, suggestion accuracy, data transmission equipment, teleconsultation duration, adherence to suggestions, impact on solving clinical problems and training utility. Each question had a 5-point Likert scale ranging from 1 (lowest level of satisfaction) to 5 (highest level of satisfaction). After completing the project, TMS users and non-users were given another questionnaire to

assess its organizational impact. The first question aimed to determine whether TMS was perceived as useful or useless for three specialties. Open-ended questions were used to explore why GPs believed teleconsultations were either useful or useless and identify potential differences among specialties.

The study evaluated the benefits and necessary improvements of TMS according to GPs using a 5-point Likert scale. The benefits included timeliness of care, patient transportation savings, and resource savings. The necessary improvements were related to relationship and trust in the specialist, duration of teleconsultation, teleconsultation support staff, and reimbursement for GPs. Effectiveness was evaluated based on the appropriateness of the service for patient management through a comparison of the GP's initial action and their actual decision after specialist suggestions. Each teleconsultation concluded with two questions for the GP: what action would they have taken without TMS, and what action did they take after the teleconsultation? Data related to preventive tests and specialist visits are accurate, but admissions to EDs and hospitalizations were not validated through a follow-up.

(v) Economics examines the perspectives of both the HCS and the patient. The HCS's analysis concentrates on in-hospital visits, diagnostic examinations, and teleconsultations, with a specific focus on direct costs and savings. The cost of a teleconsultation is €18.6, encompassing all direct expenses associated with the service. Moreover, the economic value of an initial visit, including the cost for an ECG, is €34.12.

Diagnostic examination costs were based on the type of request made. Unfortunately, economic analysis of admissions to emergency departments and hospitalizations was not possible due to the lack of systematic collection of detailed information during follow-up. Patients have reported savings in travel costs, but indirect

costs have not been gathered.

Below is Table 1, which details the different types of teleconsultations carried out in small rural communities in Lombardy's mountain valleys between March 2006 and April 2008. The table shows that a total of 957 teleconsultations were conducted on 812 patients. The majority of these (927) were requested by GPs for cardiac problems. 18 and 12 consultations were requested for dermatology and diabetology specialties, respectively. Notably, none of the GPs requested teleconsultations for pulmonary problems.

Teleconsultations vary in duration depending on the type of clinical problem. Cardiac teleconsultations are the shortest, taking an average of 5.4 ± 3.7 minutes, while dermatological and diabetic teleconsultations take longer, averaging 9.5 ± 3.7 minutes.

During the implementation period of 2 years, the use rate of teleconsultations by 48 GPs from small mountain communities in the Lombardy Region who were interested in using TMS was 52%. The initial involvement of TELEMACO Project consisted of 94 GPs and the duration of teleconsultations was 2 ± 4.4 min for each session.

A study [21] discovered that GPs who used teleconsultation services had a favorable outlook on utilizing ICT and tended to collaborate with others. On average, each GP user had 19.9 teleconsultations. There was no significant contrast observed between user and non-user GPs in regard to patient numbers, post-graduate education, or geographical location. Out of the 48 GPs who utilized TMS, 24 had previous experience with the system from prior projects which potentially contributed to more comprehensive and efficient utilization of TMS.

812 patients, consisting of both males (n=407) and females (n=405), with a mean age of 61.6 ±19.4 years, underwent TMS therapy for cardiac issues, dermatological concerns, and diabetes.

Females had a notably higher average age of 66.9 ±18 years.

When comparing genders, it was discovered that females had a lower age (52.6 ± 19.0 years) than males (56.4 ± 19.4 years). Patients utilized the service multiple times over the study period, resulting in an average of 1.6 teleconsultations with their GP's clinic. This emphasizes the importance of consistent care for individuals dealing with chronic illnesses.

Teleconsultations were conducted in 30 small rural communities, which had an average population of 3,723 residents. The average distance between these communities and the nearest healthcare provider, which could be a local outpatient clinic or a hospital, where patients could receive visits and examinations, was 7.5 ± 6.2 km, equating to 12.

On average, it took 2 ± 8.2 minutes for one-way travel between the communities. Moreover, the average distance between the communities and the nearest hospital with an ED was 12.5 ± 9.

A one-way travel distance of 3 km is estimated to take around 17.6 ± 10.2 minutes, assuming access to the nearest clinics. However, this optimistic scenario does not factor in unforeseen events such as emergencies.

Underestimation of real travel times and distances occur due to traffic. Out of 48 users, 41 (85%) GPs completed an acceptance questionnaire at the end of the project (Table 2) and were highly satisfied with specialist consultations (Q1). The GPs perceived the quality offered by TMS to be well above their initial expectations, with no negative responses. All GPs reported complete satisfaction with the connection with SC (Q2), giving reason for future involvement in teleconsultations. SC provided the GPs with a clinical website which was well accepted (Q3) and equipped them with

the necessary remote data transmission devices for different specialties, resulting in slightly higher satisfaction ratings (Q4).

Although the quality of specialist recommendations for clinical issues was deemed good (Q5), some GPs didn't view the service as necessary due to their customary practice of directly prescribing in-person visits or hospital admittances. However, the clarity of these suggestions - a crucial aspect for the service's efficacy - was found to be satisfactory or even very satisfactory (Q6), indicating a high level of trust in the specialists among GPs. Furthermore, evaluations regarding the duration of teleconsultations demonstrated that they consistently met appropriate standards (Q7) compared to traditional in-person visits and long waiting lists.

In summary, the last three points address the impact of teleconsultations on GPs' activities. The agreement between specialists and GPs (Q8) was high, and the GPs followed suggested actions, demonstrating the usefulness of the TMS. The teleconsultations effectively resolved patients' clinical issues (Q9), resulting in a highly useful and effective service. Additionally, there was a similar level of satisfaction for training utility (Q10) among GPs, resulting in improved knowledge in cardiology, dermatology, and diabetology, with a positive impact on future problem management.

Table 2 shows that 94 GPs agreed to participate in teleconsultations and were later asked to fill out a questionnaire regarding organizational issues pertaining to the service. This was done regardless of whether they used teleconsultations or not. Of those surveyed, 64% completed the questionnaire. Table 3 indicates that cardiology was considered more useful for clinical practice than dermatology or diabetology.

Although all specialties were considered beneficial by GPs in terms of ease of use, timeliness, accuracy, reduction of waiting lists, transportation and costs, dermatological

and diabetic teleconsultations faced additional barriers due to a preference for face-to-face visits at the specialist's clinic. Table 3 presents the perceived utility of these teleconsultations. Organizational benefits, as shown in Table 4, were higher for cardiology compared to other specialties. However, all specialties recorded satisfactory results. The main organizational benefit was a reduction in patients' transportation, resulting in an improvement in quality of life and cost savings from the caregiver's perspective.

The provision of teleconsultations by GPs has resulted in the improvement of patient timeliness of care and a reduction in the need for secondary care, hospitalizations, and admission to EDs. The future application of teleconsultation services can be improved through four items that were perceived as important, with the first item receiving the highest score because relationship and trust in specialists are key elements that directly depend on well-known skills and expertise. Time is also a remarkable issue, and the duration of specialist consultations can be improved to limit the burden of GP's activities. Alternatively, the introduction of additional staff such as nurses or assistants could improve the service. Additionally, reimbursement for the activity conducted by GPs could contribute to improving teleconsultation use, including non-user GPs and increasing the number of remotely managed problems.

Table 4 illustrates the benefits, barriers, and control improvement brought about by the effectiveness of teleconsultations. It was projected that only experts who offered teleconsultation would receive remuneration. Table 5 outlines the kind of 927 heart-related teleconsultations. The majority (91%) of these teleconsultations involved the specialist altering the decision made by the general practitioner.

797 cases (86%) showed a savings in NHS resources and increased efficiency while 47 cases

(5%) showed improvement in timeliness. Of the 927 requests, 613 would have resulted in an appointment with the patient's GP. However, after a teleconsultation, only 7 appointments were necessary for further evaluation through face-to-face visits. Most specialist consultations required fewer hospital resources. In 397 cases, no action was necessary, resulting in significant cost savings.

Contrarily, hospitalization was required by six patients while 22 patients were in urgent need of admission to EDs. Table 5 presents information regarding Cardiac Teleconsultations Economics. Considering that TMS is used primarily in cardiology, the analysis on the economic aspect is concentrated solely on this area. According to Table 2, from the HCS's point of view, 927 cardiac teleconsultations prevented 600 cardiac visits (out of 613 requested by GPs, only 13 were carried out) and 122 ED admissions.

The economic analysis of the use of teleconsultation compared to in-clinic visits and diagnostic exams showed that teleconsultation resulted in 58 additional diagnostic exams and 6 hospitalizations. The analysis focused on direct costs and savings, with teleconsultation costing €16,834.32 and additional diagnostic exams costing €5,445.81.

On the one hand, the cost of 927 cardiac teleconsultations was €1,808.3 in addition to traditional practice without the TMS. On the other hand, direct savings for in-clinic visits amount to €20,472.00. This results in a significant economic balance, which should not be the primary focus of the project. The ultimate goal is to achieve rationalization of resources and improve the appropriateness of patients' care and management of clinical problems, leading to more remarkable benefits.

From the perspective of patients in rural communities, 927 teleconsultations were requested for 812 patients at a GP clinic. This resulted in a total direct cost savings of

€3,700.56, including €1,000.06 saved on avoided travel for ED and hospital admissions and €2,700.50 saved on in-clinic visits and diagnostic exams.

The purpose of the current study was to evaluate the effectiveness of teleconsultation services provided by TM for GPs. The integration of primary and secondary care and the improvement of the quality of care were deemed relevant and important to manage, as indicated by the acceptance of GPs. Teleconsultations have been successful in changing the attitudes of GPs towards ICT, leading to better collaborative work and the subsequent improvement in care quality. Previous research found teleconsultation to be effective in cardiology, increasing appropriate primary care and integration with secondary care. The level of concordance between intentions and consultations for cardiac problems was 9%, with 86% resulting in resource savings and 5% improving care timeliness. An economic analysis revealed substantial balance after taking into account costs and savings related to in-clinic visits, diagnostic examinations, and cardiac teleconsultations.

Although the economic benefits of telemedicine (TM) application may be considered greater than reported due to the omitted savings related to admission to emergency departments and hospitalizations, its relevance lies in its potential for widespread use. In our study, TM improved healthcare access for 812 patients residing in 30 small rural communities. However, in Italy, teleconsultation services are usually supplementary and not a specific alternative to traditional healthcare. Countries with greater physical distance between primary and secondary care may see higher benefits from TM's geographical accessibility. Additionally, the organizational structure of general practice poses barriers to its routine use in clinical settings. Trust in specialists, teleconsultation duration, and workload must be considered for future integration of TM into regional

and NHS care settings.

This research has meaningful implications for society and politics. It has shown that innovative healthcare services (HCS) can be successfully implemented over a period of two years to support primary care [19] and increase equal access to HCS [10]. These services are based on telemedicine (TM) networks that involve governments, healthcare providers, general practitioners (GPs), and even private specialist consultants in a collaborative and interdisciplinary framework. The study was conducted in small rural communities in Italy, but the approach and outcomes could also be used as guidelines for decision-makers in similar countries or geographical areas where teleconsultation is primarily supplemental. Moreover, the benefits of this approach could be high in countries where the distance between primary and secondary care is significant, to address challenges faced in rural areas [8], discourage migration from rural to urban areas [12], and generate evidence-based knowledge.

This study has limitations in its focus on teleconsultations instead of patients' continuity of care in collecting health-related data. Considering patients' follow-up could aid in understanding the service's effectiveness, beyond just efficiency, in terms of clinical outcomes. Additionally, there is an economic limitation as costs and savings related to ED admissions and hospitalizations were not analyzed due to a lack of systematic follow-up data.

------------------------------------------------ In conclusion, the study highlights how teleconsultation services through TM can benefit GPs in managing their patients and offering high-quality primary care for resolving cardiac problems. Future research should evaluate the daily application of this service through an experimental setting to understand its impact as a regular health service. ----------------------------------------------- The authors have no competing interests to declare. ----------------------------------------------- CM and PZ analyzed and assessed the

teleconsultation service while SS and PB contributed to data collection, processing, literature review, and analysis.

The objectives of the manuscript were defined by CT and GB, who also authorized data divulgence. All authors reviewed and approved the final version of the manuscript. The authors acknowledge the Lombardy Region - Health Care Directorate, Italy, as well as Dr Romana Coccaglio and Dr Valter Valsecchi, Chief Medical Officers of local health care authorities. The authors also extend thanks to all General Practitioners who participated in the TELEMACO Project in the districts of Vallecamonica, Valsassina, Oltrepo' Pavese, Alta Valseriana and Val di Scalve, Medio and Alto Lario.