"Telehealth" refers to the use of electronic services to support a broad range of remote services, such as patient care, education, and monitoring. Telehealth must be integrated into traditional ...ambulatory and hospital-based practices if it is to achieve its full potential, including addressing the six domains of care quality defined by the Institute of Medicine: safe, effective, patient-centered, timely, efficient, and equitable. Telehealth is a disruptive technology that appears to threaten traditional health care delivery but has the potential to reform and transform the industry by reducing costs and increasing quality and patient satisfaction. This article outlines seven strategies critical to successful telehealth implementation: understanding patients' and providers' expectations, untethering telehealth from traditional revenue expectations, deconstructing the traditional health care encounter, being open to discovery, being mindful of the importance of space, redesigning care to improve value in health care, and being bold and visionary.
Symptomatic intracranial hemorrhage (sICH) is the most feared complication of intravenous thrombolytic therapy in acute ischemic stroke. Treatment of sICH is based on expert opinion and small case ...series, with the efficacy of such treatments not well established. This document aims to provide an overview of sICH with a focus on pathophysiology and treatment.
A literature review was performed for randomized trials, prospective and retrospective studies, opinion papers, case series, and case reports on the definitions, epidemiology, risk factors, pathophysiology, treatment, and outcome of sICH. The document sections were divided among writing group members who performed the literature review, summarized the literature, and provided suggestions on the diagnosis and treatment of patients with sICH caused by systemic thrombolysis with alteplase. Several drafts were circulated among writing group members until a consensus was achieved.
sICH is an uncommon but severe complication of systemic thrombolysis in acute ischemic stroke. Prompt diagnosis and early correction of the coagulopathy after alteplase have remained the mainstay of treatment. Further research is required to establish treatments aimed at maintaining integrity of the blood-brain barrier in acute ischemic stroke based on inhibition of the underlying biochemical processes.
Although non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used to prevent thromboembolic disease, there are limited data on NOAC-related intracerebral hemorrhage (ICH).
To assess ...the association between preceding oral anticoagulant use (warfarin, NOACs, and no oral anticoagulants OACs) and in-hospital mortality among patients with ICH.
Retrospective cohort study of 141 311 patients with ICH admitted from October 2013 to December 2016 to 1662 Get With The Guidelines-Stroke hospitals.
Anticoagulation therapy before ICH, defined as any use of OACs within 7 days prior to hospital arrival.
In-hospital mortality.
Among 141 311 patients with ICH (mean SD age, 68.3 15.3 years; 48.1% women), 15 036 (10.6%) were taking warfarin and 4918 (3.5%) were taking NOACs preceding ICH, and 39 585 (28.0%) and 5783 (4.1%) were taking concomitant single and dual antiplatelet agents, respectively. Patients with prior use of warfarin or NOACs were older and had higher prevalence of atrial fibrillation and prior stroke. Acute ICH stroke severity (measured by the National Institutes of Health Stroke Scale) was not significantly different across the 3 groups (median, 9 interquartile range, 2-21 for warfarin, 8 2-20 for NOACs, and 8 2-19 for no OACs). The unadjusted in-hospital mortality rates were 32.6% for warfarin, 26.5% for NOACs, and 22.5% for no OACs. Compared with patients without prior use of OACs, the risk of in-hospital mortality was higher among patients with prior use of warfarin (adjusted risk difference ARD, 9.0% 97.5% CI, 7.9% to 10.1%; adjusted odds ratio AOR, 1.62 97.5% CI, 1.53 to 1.71) and higher among patients with prior use of NOACs (ARD, 3.3% 97.5% CI, 1.7% to 4.8%; AOR, 1.21 97.5% CI, 1.11-1.32). Compared with patients with prior use of warfarin, patients with prior use of NOACs had a lower risk of in-hospital mortality (ARD, -5.7% 97.5% CI, -7.3% to -4.2%; AOR, 0.75 97.5% CI, 0.69 to 0.81). The difference in mortality between NOAC-treated patients and warfarin-treated patients was numerically greater among patients with prior use of dual antiplatelet agents (32.7% vs 47.1%; ARD, -15.0% 95.5% CI, -26.3% to -3.8%; AOR, 0.50 97.5% CI, 0.29 to 0.86) than among those taking these agents without prior antiplatelet therapy (26.4% vs 31.7%; ARD, -5.0% 97.5% CI, -6.8% to -3.2%; AOR, 0.77 97.5% CI, 0.70 to 0.85), although the interaction P value (.07) was not statistically significant.
Among patients with ICH, prior use of NOACs or warfarin was associated with higher in-hospital mortality compared with no OACs. Prior use of NOACs, compared with prior use of warfarin, was associated with lower risk of in-hospital mortality.
Telehealth services that allow remote communication between the patient and the clinical team are an emerging part of care delivery. Given language barriers, patients with limited English proficiency ...present a unique set of challenges in integrating telehealth and ensuring equity. Using data from 84,419 respondents in the 2015-18 California Health Interview survey, we assessed the association between limited English proficiency and telehealth use (telephone and video visits) and evaluated the impact of telehealth use on health care access and use. We found that patients with limited English proficiency had lower rates of telehealth use (4.8 percent versus 12.3 percent) compared with proficient English speakers. In weighted multivariable logistic regression, patients with limited English proficiency still had about half the odds of using telehealth. Telehealth use was associated with increased emergency department use for all patients. This study suggests that policy makers and clinicians must focus on limited English proficiency as an important dimension to promote telehealth equity and decrease digital divides.
Large collaborative research networks provide opportunities to jointly analyze multicenter electronic health record (EHR) data, which can improve the sample size, diversity of the study population, ...and generalizability of the results. However, there are challenges to analyzing multicenter EHR data including privacy protection, large-scale computation resource requirements, heterogeneity across sites, and correlated observations. In this paper, we propose a federated algorithm for generalized linear mixed models (Fed-GLMM), which can flexibly model multicenter longitudinal or correlated data while accounting for site-level heterogeneity. Fed-GLMM can be applied to both federated and centralized research networks to enable privacy-preserving data integration and improve computational efficiency. By communicating a limited amount of summary statistics, Fed-GLMM can achieve nearly identical results as the gold-standard method where the GLMM is directly fitted to the pooled dataset. We demonstrate the performance of Fed-GLMM in numerical experiments and an application to longitudinal EHR data from multiple healthcare facilities.
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