Impact of School Telehealth on Access to Medical Care, Clinical Outcomes, and Cost Savings Among Children in Rural Arkansas

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Impact of School Telehealth on Access to Medical
Care, Clinical Outcomes, and Cost Savings Among
Children in Rural Arkansas

• Ann B. Bynum, EdD
• Cathy A. Irwin, PhD, RN
• Bryan L. Burke, Jr., MD, FAAP
• Matthew V. Hadley, DNP, RN, ANP, PNP-BC
• Ralph Vogel, RN, PhD, CPNP
• Patrick Evans, MEd, RRT, RN
• Denise Ragland, PharmD, CDE
• Tina Johnson, LPN

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Telehealth for Kids in Delta Schools (Telehealth
KIDS)

• Project Goal Demonstrate how telehealth can
  improve access to quality health care services in
  one of the most underserved regions of the U.S.,
  Arkansas Delta
• Catalyze improvements in clinical outcomes,
  quality of care, and cost effectiveness
• Conducted by the University of Arkansas for
  Medical Sciences (UAMS), Center for Distance
  Health
• Funded by the Office for the Advancement of
  Telehealth, HRSA, DHHS

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Telehealth KIDS Project

• 2-Year Project August, 2007-August, 2009
• Asthma Telemonitoring 2007-2009
• Diabetes Telemonitoring 2008-2009
• Telehealth consults 2 Elementary Schools, 1
  Middle School,1 High School, Marianna, AR
• Daily peak flow, FEV1, pulse oximetry, blood
  glucose, blood pressure, heart rate, asthma and
  diabetes symptoms
• Medical management Asthma, diabetes, acute
  pediatric conditions
• Collaborated with local PCP
• Self-management educationAsthma, diabetes

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Marianna, Arkansas

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Initiating the Asthma and Diabetes Telemonitoring
Project

• Project Personnel, Training
• Develop evaluation forms and database to assess
  outcomes, telehealth consults
• Telemonitoring, interactive video equipment at
  the schools
• Educate school staff, teachers, parents community
  health professionals
• Protocols for telehealth consults
• Approval for data collection IRB, schools,
  healthcare facilities, hospitals
• Recruiting and referral of students

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Purpose of the Study

• Assessed access to medical care, changes in
  clinical outcomes, and cost savings among
  children participating in telehealth medical,
  asthma and diabetes telemonitoring consults in
  the school Telehealth KIDS project in the rural
  Arkansas Delta

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Significance of the Study

• Model for delivery of health services for
  children in rural, underserved areas of Arkansas
• Potential method for reaching a large number of
  children to improve access to medical care and
  health education
• Improved medical management, patient adherence,
  and clinical outcomes prevent hospital
  admissions and school absences
• School telehealth fits into health care reform

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Project Outcomes

• Access to Medical Care
• Pediatric services from pediatrician in local
  community
• Clinical and health education services
• Other health resources received in local
  community health facilities
• Referrals to Pediatric Nurse Practitioner (PNP)
  during telehealth consults
• Referrals to additional health resources for
  children and families during telehealth consults

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Project Outcomes

• School absenteeism
• Emergency room (ER) and hospital admissions for
  asthma
• Cost savings from reduced ER and hospital visits
  for asthma
• Metered-dose inhaler (MDI) technique
• Asthma-symptom days
• Forced expiratory flow (FEF) 25-75 predicted
• Blood glucose
• Hemoglobin A1c
• Adherence to daily glucose monitoring

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Design and Methods

• One-group pretest 3-, 6-, and 12-month follow-up
  design N 56 children and adolescents
• Baseline Sample N 40 with asthma, N 6 with
  diabetes
• Elementary, Middle, and High Schools, Marianna,
  AR
• Participated in the UAMS Center for Distance
  Health, Telehealth KIDS Project during 2007-2009
• Data Collection August, 2007-August, 2009

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Spirometry Testing
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Assessment of MDI Technique
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Asthma and Diabetes Telemonitoring Consults and
Equipment
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(No Transcript)
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Interactive Video Equipment
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Instruments

• Asthma Assessment Form
• Asthma Severity Assessment Form
• MDI Technique Checklist
• Diabetes Assessment Reporting Form
• Project Evaluation, Subject Visit Form
• Encounter Form
• Assessment Reporting Form
• Student Master Record

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Data Analysis

• Statistical Package for Social Sciences (SPSS),
  Version 17
• Longitudinal Data Analysis
• McNemar Test
• Wilcoxon Signed Ranks Test
• Paired Samples T-Test

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Characteristics of the Sample for the Telehealth
KIDS Project
Variable N Total N 56 Total
Telehealth Consults 3,135 Gender
Female 28 50 Male 28 50 Ethnicity
African-American 49 88 White 6 11
Hispanic/Mexican 1 1 School
Elementary (grades K-2, 5-8 y.o.) 37 66
Elementary (grades 3-5, 9-11 y.o.) 11 20
Middle school (grades 6-8, 12-14 y.o.) 6 10
High school (grades 9-12, 15-18 y.o.) 2
4
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Results Characteristics of the Sample for the
Asthma Project

• N 2,583 Telehealth consults for asthma
  telemonitoring, MDI assessments/education,
  spirometry testing, asthma education
• Baseline Sample N 40 children/adolescents
• Male, n 26 (65) Female, n 14 (35)
• African-American, n 37 (93)
• White, n 2 (5)
• Hispanic/Mexican, n 1 (2)
• Elementary School (grades K-2), n 18 (45)
• Elementary School (grades 3-5), n 16 (40)
• Middle School (grades 6-8), n 6 (15)

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Results Characteristics of the Sample for the
Diabetes Project

• N 546 Telehealth consults for diabetes
  telemonitoring and education
• Baseline Sample N 6 children, adolescents
• Female, n 6 (100)
• African-American, n 6 (100)
• Elementary School (grades 3-5), n 1 (17)
• Middle School (grades 6-8), n 5 (83)
• Insulin treatment, n 5 (83)
• Oral diabetic medications, n 1 (17)
• Overweight, n 6 (100)
• Children with Asthma, n 2 (33)

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Results Access to Medical Care, Baseline and
12-Month Follow-up
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Access to Medical Care for Children in the
Telehealth KIDS Project
Access to Medical Care Baseline
12-mo FU n n
P Value Received pediatric services from a
pediatrician in local community 2
7 0 0 .50 Received clinical
services in local community 9 32
2 7 .07 Received health
education in local community 4
14 7 25 .55 Received other health
resources in local community 5
18 1 4 .22
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Access to Medical Care

• During 9/07-8/08 Referrals to PNP during 2,625
  (84) telehealth consults
• At 12-month follow-up Referrals to PNP during
  875 (28) consults
• During 9/07-8/08 Referrals to additional health
  resources for children and families during 1,939
  (62) telehealth consults
• At 12-month follow-up, referrals to additional
  health resources during 1,309 (42) consults
• Health resources Asthma and diabetes education,
  lung function testing, inhaler technique
  assessment and education

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Results ER and Hospital Admissions

• No significant decrease in ER admissions (N
  15), over time from baseline (M 0.20) to
  12-month follow-up (M 0.20, p 1.00)
• Decreased hospital admissions (N 15), over time
  from baseline (M 0.20) to 12-month follow-up (M
  0.00)
• No significant decrease in hospital admissions
  over time (p .25)
• Mean decline of 0.20 hospital admissions per
  student from baseline at 12-month follow-up
• 100 decline in hospital admissions at 12-month
  follow-up for the 3 children who had hospital
  admissions at baseline

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Results Cost Savings

• From reduced hospital admissions, the average
  cost savings per participating child (N 15) was
  168.40 at 12-month follow-up (0.20 X 842.00
  168.40)
• Total cost savings (N 15) in Medicaid
  reimbursement costs was 2,526.00 (15 X 168.40
  2,526.00)
• At 12-month follow-up, the average cost savings
  for each of the 3 children who had hospital
  admissions at baseline was 842.00.

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Results School Absences

• Children with asthma participating in baseline
  and 12-month follow-up (N 15)
• Showed a trend of having fewer school absences,
  over time from baseline (M 4.33) to 12-month
  follow-up (M 2.87)
• No significant reduction in school absences over
  time (Z -0.67, p .50).
• Six children demonstrated a trend of having
  decreased school absences from baseline to the
  12-month follow-up.
• Children with asthma reduced their school
  absences by 34 at 12-month follow-up.

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Results Asthma-Symptom Days

• Children with asthma showed a trend of having
  fewer asthma-symptom days at daytime from
  baseline(BL) (N 39, M 3.26 ) to 12-month
  follow-up (FU) (N 15, M 1.33, slope est.
  -0.02, p .73)No significant reduction in
  asthma-symptom days
• While exercisingFewer asthma-symptom days from
  BL (M 2.56) to 20-month FU (N 7, M
  0.86, slope est. -0.07, p .16) No
  significant reduction in asthma-symptom days
• Showed a trend of having more asthma-symptom days
  at night from BL (M 2.08) to 20-month FU (M
  2.86, slope est. 0.06, p .31)No
  significant increase in asthma-symptom days

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Results FEF 25-75 Predicted, MDI Technique

• Children with asthma Significant reduction in
  FEF 25-75 predicted from BL (N 39, M
  0.74 ) to 12-mo FU (N 10, M 0.55, slope est.
  -0.02, p lt .01)No improvement
• Significant improvement in MDI technique from BL
  (N 40) to 15-month FU (N 8)
• For mean total scores (BL M 3.75, FU M
  5.88, slope est. 0.17, p lt .01)
• For 3 steps for MDI technique
• Shakes inhaler (slope est. 0.03, p
  .05, approached significance)
• Exhales normally (slope est. 0.04, p lt
  .01)
• Holds med. in lungs 10 secs. before exhaling
  (slope est. 0.04, p lt .01)

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Results Blood Glucose, Hemoglobin A1c, Adherence
to Daily Glucose Monitoring

• Children with diabetes (N 6) Decreased blood
  glucose from BL (M 285.17 mg/dL) to
  6-month FU (M 209.83 mg/dL, p .18)No
  significant reduction in blood glucose
• Increased hemoglobin A1c from BL (M
  8.67) to 3-month FU (N 6, M
  9.35, p .37) and 6-month FU (N 5, M
  10.00, p .21)No significant increase in
  hemoglobin A1c, No improvement
• Improved adherence to daily glucose monitoring
  from BL (n 3, 50) to 6-mo FU (n 6,
  100)increased by 50 at 6-mo FU

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Conclusions and Implications

• School Telehealth improved access to medical care
  for children in the rural, Arkansas Delta.
• Demonstrated positive clinical outcomes and cost
  savings in Medicaid reimbursement costs
• Effective strategies Daily asthma, diabetes
  monitoring improved medical management,
  adherence collaboration with PCP asthma,
  diabetes education 2-yr. program interventions
  follow-up evaluation of outcomes School
  Telehealth Nurse, interdisciplinary healthcare
  team
• Future research Experimental research designs
  with larger samples, minority ethnic groups in
  rural communitiesassess clinical, health
  behavior outcomes access to medical care, and
  cost savings