Medical Consultations With Webcams Extremely Successful

AgaveNectar writes "Doctors are far from being early adopters, so they have just gotten around to publishing a report that webcams help immensely with making the right decision when someone shows up to a rural emergency room suffering from a stroke. Using clot-destroying medications like Alteplase is really risky, and it should only be given in acute cases. In a study of 222 patients, rural ER doctors consulted with faraway stroke specialists. They made the right decision 98 percent of the time when the expert examined the patient with a webcam, and only 82 percent of the time when they just talked to each other on the phone. Perhaps this report will finally convince the medical community that telemedicine is important."

Comments

Next, outsourcing to Bangalore

[Animats]

Now, at last, medical care can be outsourced to low-wage countries.

Re:Next, outsourcing to Bangalore

[ColdWetDog]

I'm not sure that I call transmission of digital information 'telemedicine' but we use remote radiology all the time since we are too rural to afford a full time radiologist.

I'll call them up and tell them that Portland, Oregon is officially considered a "low wage country". I bet they will be surprised!

Are they using SSL?

[seanonymous]

Will my privacy be protected, as per HIPAA, when then they stream video of me lying in a hospital bed, being less than articulate, across the interwebs?

I'm convinced telemed is important...

[NIckGorton]

But not because of this.

The problem is that this is not really a good demonstration of the efficacy of telemedicine, because they picked a treatment for which there is a marginal benefit for a very small proportion of people. In order to get thrombolytics for stroke, you have to meet a certain set of criteria that in my experience few meet: no recent trauma or surgery, normal blood pressure, no history of stroke in the past 3 months (or hemorrhagic stroke ever), no current ulcer disease, no diabetic retinopathy, no seizures, deficit is more than minor but not too major, certain onset of symptoms in under 3 hours (and it will take an hour to get you imaged and blood tests done after you get to the ER), and a lot more.

In addition, if we give you thrombolytics for your stroke (and you are an ideal candidate) you get a 13% greater chance to recover with minimal or no deficit, but you have a 7% greater chance of your stroke getting phenomenally worse by becoming a hemorrhagic stroke which more often than not leave you dead or in a permanent vegetative state (in addition to all the other problems you can get from being completely incapable of clotting for a good 24 hours.)

What they should do is demonstrate this where it could be really useful: with a NP or PA way off in the hinterlands or in underdeveloped countries. But that isn't snazzy, doesn't pay well, and drug companies that sell gazillion dollars a pop medicines don't sponsor it.

Re:I'm convinced telemed is important...

[ColdWetDog]

Agreed and arg!

From the FA (no, not the stupid Wired blurb, the one in Lancet):

Correct treatment decisions were made more often in the telemedicine group than in the telephone group (108 [98%] vs 91 [82%], odds ratio [OR] 109, 95% CI 27-446; p=00009)

Not awfully shabby, small study though. No power analysis (how many patients would be needed to validly determine if an 18% difference in 'outcomes' was real). Note the hedging on outcomes - here is the real problem with the study.

Intravenous thrombolytics were used at an overall rate of 25% (31 [28%] telemedicine vs 25 [23%] telephone, 13, 07-25; p=043).

Not all that different here. Note the lousy p-value. So, you do pretty much the same if you got it 'right' or 'wrong'. Interesting.

90-day functional outcomes were not different for BI (95-100) (06, 04-11; p=013) or for mRS score (06, 03-11; p=009). There was no difference in mortality (16, 08-34; p=027) or rates of intracerebral haemorrhage after treatment with thrombolytics (2 [7%] telemedicine vs 2 [8%] telephone, 08, 01-63; p=10).

Blast and damn. No difference no matter what the hell you do.

However, there were more incomplete data in the telephone group than in the telemedicine group (12% vs 3%, 02, 01-03; p=00001).

Whatever that means. Again, no functional difference no matter what you do.

So yeah, not much to see here, move along. Nothing like overruning your data with conclusions. If you're an ER doc (and I am one) you should really be able to describe the neurologic exam of someone having a fairly large, well defined stoke to a neurologist on the other side of the phone. If you can't you can look it up. Not that the webcam is any great technological milestone but the article basically showed that it's use made no difference to the patient

Re:I'm convinced telemed is important...

[edsyc]

If you're an ER doc, what makes you qualified to criticize their statistics?

1) It is impressive that they managed to recruit so many patients for such a complicated study, and I don't think their sample size is that small in the first place.

2) If you do a power analysis, it won't tell you whether the 18% difference is "real" after you've already established statistical significance.

3) Regarding intravenous thrombolytics: So the 28% vs 23% is "not all that different". But could it make a difference to a few patients? The "lousy p-value" (p=.043) indicates a significant difference at alpha=.05, so I have no idea why you call it lousy.

Your post basically showed that ER docs will use the year of stats classes that they took in school to interpret research any damn way they want to.

A more interesting study

[nasor]

I would like to see a study comparing patient's success rates at self-diagnosis with google vs. a doctor's diagnosis success rate. Every time I've had to go to the doctor lately I've successfully diagnosed myself with the internet and known the treatment before I went, only to pay $120 for a doctor to look at me for 5 minutes and say what I had already guessed.