Journal Article Annotations
2021, 4th Quarter

Neuropsychiatry

Annotations by Brandon A Francis, MD, MPH
December, 2021

Patient perception of physician empathy in stroke telemedicine.
Psychiatrist and Psychologist Experiences with Telehealth and Remote Collaborative Care in Primary Care: A Qualitative Study.
Provider Satisfaction from a New Telepsychiatry Inpatient Consultation Service.

PUBLICATION #1 — Neuropsychiatry

Patient perception of physician empathy in stroke telemedicine.

Molly Howland, McKenna Tennant, Deborah J Bowen, Amy M Bauer, John C Fortney, Jeffrey M Pyne, Jay Shore, Joseph M Cerimele

Abstract: J Telemed Telecare. 2021 Oct;27(9):572-581. doi: 10.1177/1357633X19899237. Epub 2020 Jan 27.

Introduction:
We assessed patients’ perceptions of physician empathy during telemedicine consultations as compared to in-person consultations during clinical encounters for acute stroke.

Methods:
This prospective cohort study was undertaken at a comprehensive stroke centre hub in collaboration with a distant community hospital spoke site. Eligible participants presented to hub or spoke emergency departments with suspected acute stroke within three hours of symptom onset. Participants were evaluated at the hub site in person or at the remote site via telemedicine by the same group of neurologists. Following acute care decisions, single-visit data including participant-reported assessments of physician empathy were collected within 24 h. The primary outcome was the Consultation and Relational Empathy score. The secondary outcome for the telemedicine cohort was the Telemedicine Patient Satisfaction Measure score.

Results:
Between 31 May 2013-13 March 2019, 70 patients completed the study. Fifty patients were seen by telemedicine and 20 patients were seen in person. Median Consultation and Relational Empathy scores (with a possible score of 10-50) were 49 (range 27-50) for telemedicine and 45 (range 26-50) for in-person consultations (Wilcoxon rank sum p = 0.18). Each item of the Consultation and Relational Empathy questionnaire was rated very good or excellent by at least 87% of participants in the telemedicine group. The median Telemedicine Patient Satisfaction Measure score was 54 (range 12-60), with each item rated agree or strongly agree by at least 84% of participants.

Discussion:
We found no difference between telemedicine and in-person visits in patient perception of physician empathy in acute stroke care. Therefore, we conclude that empathy can be conveyed by facial expression, voice and attentiveness in a telemedicine encounter and, in the setting of acute stroke care, does not require physical touch or proximity.

Annotation

The finding:
This is a prospective cohort study that evaluated perspectives on provider empathy from 70 adult stroke patients in the Emergency Department using the Consultation and Relational Empathy (CARE) questionnaire. The authors found no difference in reports of provider empathy from patients seen in-person or through tele-medicine. Those seen through tele-medicine were younger (p = 0.04), had lower rates of cognitive deficits (p= 0.02), and lower NIHSS scores (p = 0.03; National Institutes of Health Stroke Scale – lower scores are associated with less severe functional impairment). The consultation time was also shorter in those who engaged in telemedicine (p=0.04). There was no difference in rates of tPA administration (p = 0.17) which is a time-sensitive potentially therapeutic intervention that has been associated with improved functional outcomes in patients with acute ischemic stroke at 90 days. In a multivariate analysis the authors controlled for consultation duration, NIHSS, age and found no difference in ‘good to excellent’ CARE rating ((odds ratio (TM vs in-person) = 1.72, 95% confidence interval (CI) 0.43–7.70, p = 0.48).

Strengths and weaknesses:
This study had significantly more patients in the telemedicine arm of the study. This was unblinded and therefore subject to bias as evidenced by the statistically significant difference in patient demographics between groups (ex: age). The sample size was small (n = 70) and was conducted in a setting where there was already a good working relationship between the primary hospital and its hub which may limit generalizability. This study’s main strength is that they employed a multivariable analysis to control for some of those potential confounders that strengthens the results.

Relevance:
study can inform our perspectives on engaging in telepsychiatric consultations in settings where in-person connection is not possible or logistically challenging. From this study we can reasonably suspect that at least a cohort of younger, cognitively intact patients being evaluated for a stroke seem to tolerate telehealth in the emergent environment. There seems to be no significant difference in perceptions of empathy in this patient population when comparing in-person vs telehealth. The next step would be to validate this in a small psychiatric population given there can be significant differences in the development of rapport and availability of resources such as ongoing patient support post-consultation.

PUBLICATION #2 — Neuropsychiatry

Psychiatrist and Psychologist Experiences with Telehealth and Remote Collaborative Care in Primary Care: A Qualitative Study.

Mohammed El-Dallal, Ariana Saroufim, Hannah Systrom, Sarah Ballou, Adel Farhoud, Ravi Teja Pasam, Salini Samyuktha Gadupudi, Karim Osman, Khadija Chaudrey, Adam Cheifetz, Joseph D Feuerstein./span>

Abstract: J Rural Health. 2021 Sep;37(4):780-787. doi: 10.1111/jrh.12523. Epub 2020 Oct 6.

Purpose:
Availability of mental health services is limited in the rural United States. Two promising models to reach patients with limited access to care are telehealth referral and collaborative care. The objective of this study was to assess telepsychiatrist- and telepsychologist-level facilitators and barriers to satisfaction with and implementation of these 2 telehealth models in rural settings.

Methods:
Focus groups were held in 2019 using a semistructured interview guide. Participants were off-site telepsychiatrists (N = 10) and telepsychologists (N = 4) for primary care clinics across 3 states (Washington, Michigan, and Arkansas) involved in a recent pragmatic comparative effectiveness trial. Qualitative analysis occurred inductively by 2 independent coders.

Findings:
Participants were satisfied with the models partly owing to good patient rapport and expanding access to care. Teamwork was highlighted as a facilitator in collaborative care and was often related to work with care managers. However, participants described communication with primary care providers as a challenge, especially in the telehealth referral arm. Barriers centered on variability of logistical processes (eg, symptom monitoring, scheduling, electronic medical record processes, and credentialing) among sites. Staff turnover, variable clinic investment, and inadequacy of training were possible explanations for these barriers.

Conclusions:
Participants described high motivation to provide team-based, remote care for patients, though they experienced operational challenges. Centralized credentialing, scheduling, and record keeping are possible solutions. These findings are important because consulting psychiatrists and psychologists may play a leadership role in the dissemination of these models.

Annotation

The finding
This multisite study assembled focus groups of providers, psychiatrists, and psychologists who were participating in the remote care of their patients. The primary objective was to ascertain provider barriers to tele-health. The authors found that the providers were motivated to participate, but there were various operational challenges including but not limited to electronic medical record function, communication with other providers such as primary care, technological challenges, and credentialing at various sites.

Strengths and weaknesses
This study is related to a larger comparison of telepsychiatry to a collaborative care model which included just over 1000 patients referred to as the SPIRIT (the Study to Promote Innovation in Rural Integrated Psychiatry) trial. That study was aimed at addressing unmet psychiatric needs in rural communities. This study evaluated the perspective of the providers who were part of that SPIRIT trial. This provider focus-group based study had only 10 providers participate. The sample size is small which can limit the interpretation of the results. However, given the paucity of data on provider perspective on telepsychiatry in this context, any information can be a helpful starting point. This was a qualitative study limiting statistical utility.

Relevance
In the current COVID environment telepsychiatry has become more common, and these data seem to reflect the challenges of the everyday process of engaging in remote care. The authors highlight the importance of patient rapport, teamwork such as with case workers and improving access to care. They also address some of the challenges these providers experienced during the study period. While the n is small – only 10 participants – their experience will likely resonate with others engaged in telepsychiatry. The next steps include a large sample of providers and integrating resources to limit the impact of operational challenges that can plague remote telehealth.

PUBLICATION #3 — Neuropsychiatry

Provider Satisfaction from a New Telepsychiatry Inpatient Consultation Service.

Michael S Yoon, Katherine B Martin, Rory L Marraccini, Edward R Norris

Abstract: Telemed J E Health. 2021 Oct;27(10):1129-1135. doi: 10.1089/tmj.2020.0317. Epub 2021 Jan 20.

Background & aims:
Integrated inflammatory bowel disease (IBD) care is effective but not routinely implemented. Validated methods that simultaneously address mind and body targets such as resilience may improve access and outcomes. We describe the development and implementation of the GRITT method and its impact on resilience, health care utilization (HCU), and opioid use in IBD.

Background:
Telepsychiatry is a well-studied modality that has been shown to perform as well as, if not better than, in-person mental health services. However, acceptability of this modality to practitioners, especially as it relates to the type of consult, has not been well studied. To address barriers to implementing a new telepsychiatry consultation-liaison (CL) service at a rural campus of a large tertiary care health network, authors designed a survey to assess consultee attitudes before and after the service launch. A secondary objective was to examine the consult data.

Materials and Methods:
The new telepsychiatry CL service at the rural hospital was delivered by providers at the main campus of the health network. Authors surveyed all consultees before the launch and every 3 months for 12 months thereafter. Consult data was also tracked in that same period.

Results:
Over a 12-month period, 442 initial and follow-up consults were completed. Consultees were most concerned with assessing delirium, agitation, and neurocognitive disorder over live video. Consultees generally held their belief that telepsychiatry consults are not as enjoyable as in-person consults, but they recognized its value, specifically regarding improved access for patients.

Discussion:
The service was successfully launched and was well received as evidenced by the continued use of the service.

Conclusions:
The project revealed valuable insight which has been used to improve the service and to replicate it at another campus within the health network.

Annotation

The finding:
This observational study was conducted in the context of initiating a new tele-consultation-liaison psychiatry service for a remote hospital. The primary objective was to evaluate provider perspectives of this service. The providers in general did not find these remote consultations as rewarding or fulfilling as in-person consultations. The providers did appreciate the positive impact on the care of patients that would otherwise have gone without their consultation services.

Strength and weaknesses:
This is a qualitative study and only a small number of providers participated. This limits generalizability and statistical utility. However, there is limited data on provider perspectives in the context of initiating a CL service remotely.

Relevance:
This study offers provider perspectives on new remote CL services. These are likely shared among a cohort of psychiatrists, however, a larger sample size is needed to determine what components should be the topics of focus when building such a service.