Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): Telemedicine Systems (Hospital),

Intervention Description: The availability of postpartum care through telehealth, either via video and audio or audio only, starting on March 16, 2020. Before this date, all postpartum visits at our institution were performed in-person. However, after this date, outpatient obstetrics clinics recommended telehealth postpartum visits as the primary modality for visits while also offering some limited in-person postpartum visits.

Intervention Results: Subjects in the postimplementation group were at 90% increased odds of attending a postpartum visit compared with those in the preimplementation group, even when controlling for race, prenatal care provider, parity, gestational age at delivery, and insurance status. Patients in the postimplementation group were also more likely to be screened for postpartum depression (86.3% vs 65.1%; P<.001)

Conclusion: Availability of telehealth during the COVID-19 pandemic is associated with increased postpartum visit attendance and postpartum depression screening. However, telehealth was also associated with a decrease in use of long-acting reversible contraception or permanent sterilization.

Study Design: Retrospective cohort study

Setting: Department of Obstetrics & Gynecology, University of Pennsylvania

Population of Focus: Postpartum women enrolled in Medicaid

Sample Size: 1,759 (780 in preimplementation group 799 in postimplementation group(

Age Range: 25-34

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Access to Provider through Hotline, HOSPITAL, Continuing Education of Hospital Providers, POPULATION-BASED SYSTEMS, INTER-HOSPITAL SYSTEMS, Maternal/In-Utero Transport Systems, STATE, Policy/Guideline (State), Consultation Systems (Inter-Hospital Systems), Consultation Systems (Hospital), Telemedicine Systems (Inter-Hospital Systems), Telemedicine Systems (Hospital)

Intervention Description: To examine the factors associated with delivery of preterm infants at neonatal intensive care unit (NICU) hospitals in Arkansas during the period 2001–2006, with a focus on the impact of a Medicaid supported intervention, Antenatal and Neonatal Guidelines, Education, and Learning System (ANGELS), that expanded the consulting capacity of the academic medical center's maternal fetal medicine practice.

Intervention Results: Perceived risk, age, education, and prenatal care characteristics of women affected the likelihood of use of the NICU. The perceived availability of local expertise was associated with a lower likelihood that preterm infants would deliver at the NICU. ANGELS did not increase the overall use of NICU, but it did shift some deliveries to the academic setting.

Conclusion: Perinatal regionalization is the consequence of a complex set of provider and patient decisions, and it is difficult to alter with a voluntary program.

Study Design: Time trend analysis

Setting: All Arkansas hospitals Five level III hospitals from 2001- 2005, six in 2006

Population of Focus: Infants born at <35 weeks GA

Data Source: Data from Medicaid claims for pregnancy linked to birth certificates for women covered by Medicaid in Arkansas

Sample Size: Total (n= 5,150) 2001 (n= 812) 2002 (n= 1,105) 2003 (n= 824) 2004 (n= 824) 2005 (n= 887) 2006 (n= 698) Infants born at <35 weeks GA

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Telemedicine Systems (Hospital),

Intervention Description: The intervention described in this study is a virtual wraparound care program called "vKids." The program provided comprehensive care coordination, education, parental support, acute care triage, and virtual visits to children with medical complexity (CMC) and their families. The program utilized a virtual team of pediatric physicians, pediatric nurse practitioners, pediatric nurses, and social workers to address the medical and social needs of patients and families. The program was designed to address the challenges faced by families of CMC, including geographic barriers, transportation challenges, and the lack of reimbursement for the level of support services and care coordination needed.

Intervention Results: Eighty (n = 80) children were included in the economic evaluation, and 75 had sufficient data for analysis. Compared to the 12 months before enrollment, patients had a 35.3% reduction in hospitalizations (p = 0.0268), a 43.9% reduction in emergency visits (p = 0.0005), and a 16.9% reduction in overall charges (p = 0.1449). Parents expressed a high degree of satisfaction, with a 70% response rate and 90% satisfaction rate.

Conclusion: We implemented a virtual care model to provide in-home support and care coordination for medically complex children and adolescents and used an economic framework to assess changes in utilization and cost. The program had high engagement rates and parent satisfaction, and a pre/postanalysis demonstrated statistically significant reduction in hospitalizations and ED visits for this high-cost population. Further economic evaluation is needed to determine sustainability of this model in a value-based payment system.

Study Design: The study utilized a retrospective cohort design to measure the pre-intervention and post-intervention utilization for inpatient, outpatient, and emergency department settings, as well as the cost of care and patient satisfaction for children with medical complexity (CMC). The economic framework was used to evaluate the outcomes of the virtual wraparound care program, and data for study participants were extracted from the HIDI dataset for all inpatient and outpatient visits across all hospitals in the state between October 1, 2017, and March 31, 2020.

Setting: The study was conducted in the United States, specifically in the states of Missouri, Tennessee, and North Carolina. The program was implemented in a virtual care setting, providing wraparound care to address the medical and social needs of patients and families using a virtual team of pediatric physicians, pediatric nurse practitioners, pediatric nurses, and social workers.

Population of Focus: The target audience for the study includes healthcare professionals, policymakers, and researchers interested in pediatric care, particularly for children with medical complexity (CMC). Additionally, the findings of the study may be relevant to healthcare administrators and organizations seeking to implement or improve virtual care programs for pediatric patients with complex medical needs. The study's focus on the economic evaluation and outcomes of a virtual wraparound care program makes it particularly relevant to those interested in innovative care models and their impact on healthcare utilization and patient satisfaction.

Sample Size: The study included a total of 80 children with medical complexity (CMC) for the economic evaluation, and 75 of these children had sufficient data for analysis. The sample size of 75 patients was used for the pre- and post-analysis of the program's impact on hospitalizations, emergency department visits, and overall charges.

Age Range: 0-19 years

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Access to Provider through Hotline, HOSPITAL, Continuing Education of Hospital Providers, POPULATION-BASED SYSTEMS, INTER-HOSPITAL SYSTEMS, Maternal/In-Utero Transport Systems, Consultation Systems (Inter-Hospital Systems), Consultation Systems (Hospital), Telemedicine Systems (Inter-Hospital Systems), Telemedicine Systems (Hospital), STATE, Policy/Guideline (State)

Intervention Description: Telemedicine has been used successfully for medical care and education but it has never been utilized to modify patterns of delivery in an established state network.

Intervention Results: Medicaid deliveries at the regional perinatal centers increased from 23.8% before the intervention to 33% in neonates between 500 and 999 grams (p<0.05) and was unchanged in neonates between 2001-2500 grams.

Conclusion: Telemedicine is an effective way to translate evidence based medicine into clinical care when combined with a general educational conference. Patterns of deliveries appear to be changing so that those newborns at highest risk are being referred to the regional perinatal centers.

Study Design: Time trend analysis

Setting: All Arkansas hospitals

Population of Focus: Infants born weighing 500-2499 gm. Data not given for other study years.

Data Source: Data from Arkansas Vital Statistics Data System linked with corresponding hospitalization records from Arkansas Hospital Discharge Data System.

Sample Size: Total (n= 12,258) 2001 (n= 2,965) 2004 (n= 3,154)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Telemedicine Systems (Hospital), Family-Based Interventions,

Intervention Description: Services for Children with Special Healthcare Needs (CSHCN) have been challenging in terms of cost and access to appropriate healthcare services. The objectives of this study were to examine cost, caring, and family-centered care in relationship to pediatric specialty services integrating telemedicine visits compared to traditional face-to-face visits only for (CSHCN) in rural, remote, and medically underserved areas.

Intervention Results: Results indicated no significant differences in family costs when the telemedicine group was compared to traditional face-to-face care. When the telemedicine group was asked to anticipate costs if telemedicine was not available, there were significant differences found across all variables, including travel miles, cost of travel, missed work hours, wages lost, child care cost, lodging cost, other costs, and total family cost (p < 0.001). There were no differences in the families' perceptions of care as caring. Parents/guardians perceived the system of care as significantly more family-centered when using telemedicine (p = 0.003).

Conclusion: The results of this study underscore the importance of facilitating access to pediatric specialty care by use of telemedicine. We endorse efforts to increase healthcare access and decrease cost for CSHCN by expanding telemedicine and shaping health policy accordingly.

Study Design: Prospective, quasiexperimental study

Setting: Department of Health Children's Medical Services (CMS), Title V Program

Population of Focus: Parents or legal guardians of Children with Special Healthcare Needs (CSHCN) enrolled in the Florida Department of Health Children's Medical Services (CMS), Title V Program in the Southeast Region of Florida. The sample included families with household incomes below 200% of the Federal Poverty Level (FPL) who had children requiring pediatric specialty care.

Sample Size: 222 parents or legal guardians of CSHCN receiving pediatric specialty care. The traditional group (n = 110) included families receiving face-to-face pediatric specialty care and the telemedicine group (n = 112) included families who had telemedicine visits along with traditional face-to-face pediatric specialty care.

Age Range: Adult parents or legal guardians of chlildren receiving care ages 0 to 17 years

Intervention Components (click on component to see a list of all articles that use that intervention): Telemedicine Systems (Hospital),

Intervention Description: Postpartum home telehealth with remote blood pressure monitoring.

Intervention Results: Significantly more women in the intervention group than the control group had at least one blood pressure measured within ten days postpartum (202 [94.4%] vs. 129 [60.3%], aRR 1.59, 95% CI: 1.36–1.77). Postpartum home telehealth with remote blood pressure monitoring was associated with reduced readmissions compared to standard care. The intervention group had fewer hypertension-related readmissions compared to the control group (1 [0.5%] vs. 8 [3.7%], aRR 0.12; 95% CI: 0.01–0.96).

Conclusion: Telehealth with remote blood pressure monitoring and standardized management of postpartum hypertension was associated with reduced readmissions compared to standard care. The study suggests that telehealth with remote blood pressure monitoring offers a promising strategy for achieving higher acquisition of blood pressure measurements, early identification and treatment of uncontrolled hypertension, and ultimately reducing hospital readmissions.

Study Design: Non-randomized control trial

Setting: The UnityPoint Health-Meriter healthcare facility and the Department of Obstetrics and Gynecology at the University of Wisconsin, Madison

Population of Focus: Postpartum women with hypertensive disorders of pregnancy

Sample Size: 428 women (214 control group; 214 intervention group)

Age Range: Childbearing age

Intervention Components (click on component to see a list of all articles that use that intervention): Telemedicine Systems (Hospital),

Intervention Description: To determine whether the introduction of telemedicine at a rural pediatric clinic was associated with reduced disparities in visit attendance. A retrospective cohort study was conducted of all clinic visits from 1 January 2019 to 31 December 2021. Visit types were divided into telemedicine visits, in-person urgent, and in-person non-urgent visits. Visits were stratified into periods based on the statewide pandemic response.

Intervention Results: A total of 8,412 patients with 54,746 scheduled visits were analyzed. Visits were less likely to be completed for older patients, Black patients, and patients with Medicaid insurance than their counterparts. Despite a pandemic-era increase in telemedicine utilization, disparities in visit completion that were present in the pre-pandemic era persisted after stay-at-home orders were lifted.

Conclusion: The adoption of telemedicine did not reduce pre-existing disparities in visit attendance. Further work is needed to identify the reasons for the disparities and improve visit attendance of historically disadvantaged patient populations.

Study Design: Retrospective cohort study

Setting: A rural academic pediatric primary care clinic serving children across the rural area of North Carolina

Population of Focus: Established patients aged 18 years or younger who received care at a rural academic pediatric primary care clinic in North Carolina

Sample Size: 8,412 children and youth

Age Range: Children and youth 0-18 years of age

Intervention Components (click on component to see a list of all articles that use that intervention): Telemedicine Systems (Hospital),

Intervention Description: A remote, text message-based blood pressure monitoring program known as Heart Safe Motherhood.

Intervention Results: 192 (96.5%) participants submitted at least 1 blood pressure measurement via text message to the program. Elevated blood pressures were recorded for 70 (35%) participants, 32 (16%) of whom were started on oral antihypertensives after discussing their blood pressure measurements with an on-call provider. A total of 10 participants (5%) required hypertension-related readmission after delivery.

Conclusion: Postpartum participants are willing and capable of using the Heart Safe Motherhood program for remote blood pressure monitoring and reported high satisfaction with the program across multiple sites. Our study demonstrated that this remote blood pressure monitoring program can be implemented successfully and demonstrated replicable efficacy at diverse sites.

Study Design: Prospective implementation design

Setting: Three different academic settings in the U.S.

Population of Focus: Postpartum people with hypertensive disorders of pregnancy (HDP) who were enrolled in the Heart Safe Motherhood program.

Sample Size: 199 participants across three academic medical centers

Age Range: Childbearing age

Intervention Components (click on component to see a list of all articles that use that intervention): Transition Assistance, PATIENT/CONSUMER, HOSPITAL, Continuing Education of Hospital Providers, POPULATION-BASED SYSTEMS, INTER-HOSPITAL SYSTEMS, Neonatal Back-Transport Systems, Consultation Systems (Inter-Hospital Systems), Consultation Systems (Hospital), Telemedicine Systems (Inter-Hospital Systems), Telemedicine Systems (Hospital)

Intervention Description: Assessed a telemedicine (TM) network's effects on decreasing deliveries of very low birth weight (VLBW, <1500 g) neonates in hospitals without Neonatal Intensive Care Units (NICUs) and statewide infant mortality.

Intervention Results: Deliveries of VLBW neonates in targeted hospitals decreased from 13.1 to 7.0% (P=0.0099); deliveries of VLBW neonates in remaining hospitals were unchanged. Mortality decreased in targeted hospitals (13.0% before TM and 6.7% after TM). Statewide infant mortality decreased from 8.5 to 7.0 per 1000 deliveries (P=0.043).

Conclusion: TM decreased deliveries of VLBW neonates in hospitals without NICUs and was associated with decreased statewide infant mortality.

Study Design: QE: pretest-posttest

Setting: All Arkansas hospitals (Nine selected as telemedicine hospitals due to high patient volume)

Population of Focus: Infants born weighing <1500 gm

Data Source: Medicaid data for VLBW infants as indicated by ICD-9 diagnosis codes from hospital and physician claims for pregnancy. Data infant with birth and infant death certificates.

Sample Size: Pretest (n= 383) Posttest (n= 384)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Telemedicine Systems (Hospital),

Intervention Description: Telehealth implementation of postpartum care during COVID

Intervention Results: In the preimplementation period, Black patients were less likely to attend a postpartum visit than non-Black patients (63.9% in Black patients vs 88.7% in non-Black patients; adjusted odds ratio, 0.48; 95% confidence interval, 0.29-0.79). In the postimplementation period, there was no difference in postpartum visit attendance by race (79.1% in Black patients vs 88.6% in non-Black patients; adjusted odds ratio, 0.74; 95% confidence interval, 0.45-1.21). In addition, significant differences across races in postpartum depression screening during the preimplementation period became nonsignificant in the postimplementation period. Telehealth implementation for postpartum care significantly reduced racial disparities in postpartum visit attendance (interaction P=.005).

Conclusion: Telehealth implementation for postpartum care during the COVID-19 pandemic was associated with decreased racial disparities in postpartum visit attendance.

Study Design: Retrospective cohort study

Setting: Urban tertiary care center with two clinical sites providing remote telehealth care

Population of Focus: Black and non-Black birthing people pre- and post-pandemic

Sample Size: 1579

Age Range: 27-35

Intervention Components (click on component to see a list of all articles that use that intervention): Telemedicine Systems (Hospital), Quality Improvement/Practice-Wide Intervention,

Intervention Description: Telemedicine is widely used but has uncertain value. We assessed telemedicine to further improve outcomes and reduce costs of comprehensive care (CC) for medically complex children.

Intervention Results: Between August 22, 2018, and March 23, 2020, we randomly assigned 422 medically complex children (209 to CC with telemedicine and 213 to CC alone) before meeting predefined stopping rules. The probability of a reduction with CC with telemedicine versus CC alone was 99% for care days outside the home (12.94 vs 16.94 per child-year; Bayesian rate ratio, 0.80 [95% credible interval, 0.66-0.98]), 95% for rate of children with a serious illness (0.29 vs 0.62 per child-year; rate ratio, 0.68 [0.43-1.07]) and 91% for mean total health system costs (US$33 718 vs US$41 281 per child-year; Bayesian cost ratio, 0.85 [0.67-1.08]).

Conclusion: The addition of telemedicine to CC likely reduced care days outside the home, serious illnesses, other adverse outcomes, and health care costs for medically complex children.

Study Design: Randomized clinical trial

Setting: The High-Risk Children's Clinic (HRCC) at the University of Texas Health Science Center at Houston (UTH).

Population of Focus: Medically complex children who received care at the High-Risk Children's Clinic (HRCC) at the University of Texas Health Science Center at Houston (UTH)

Sample Size: 422 children

Age Range: Children 0-21 years of age

Intervention Components (click on component to see a list of all articles that use that intervention): Telemedicine Systems (Hospital), Training (Parent/Family), Enhanced Equitable Access

Intervention Description: N/A

Intervention Results: Of 1206 respondents, 1054 reported a usual source of care for their children. Of these respondents, 301 of 1054 (weighted percentage 28%) reported primary care telemedicine visits for their children. Factors associated with primary care telemedicine use versus nonuse included having a child with a chronic medical condition (87/301, weighted percentage 27% vs 113/753, 15%, respectively; P=.002), metropolitan residence (262/301, weighted percentage 88% vs 598/753, 78%, respectively; P=.004), greater internet connectivity concerns (60/301, weighted percentage 24% vs 116/753, 16%, respectively; P=.05), and greater health literacy (285/301, weighted percentage 96% vs 693/753, 91%, respectively; P=.005).

Conclusion: n a national sample of respondents with a usual source of care for their children, approximately one-quarter reported use of primary care telemedicine for their children as of 2022. Equitable access to primary care telemedicine may be enhanced by promoting access to primary care, sustaining payment for primary care telemedicine, addressing barriers in nonmetropolitan practices, and designing for lower health-literacy populations.

Study Design: We first compared sociodemographic factors among respondents who did and did not report a usual source of care for their children. Among those reporting a usual source of care, we used Rao-Scott F tests to examine factors associated with parent-reported use versus nonuse of primary care telemedicine for their children.

Setting: AmeriSpeak panel survey

Population of Focus: Families using telemedicine

Sample Size: 1206

Age Range: 0-17

Intervention Components (click on component to see a list of all articles that use that intervention): Telemedicine Systems (Hospital), Patient Reminder/Invitation,

Intervention Description: The project team created four interventions to address gaps and increase attendance to the 6‐week comprehensive postpartum visit: a schedule log, postpartum telehealth check‐in visit, administering the EPDS within 6 weeks postpartum (during the telehealth check‐in visit), and a team engagement plan. Appointments for a telehealth check‐in visit and a comprehensive postpartum visit were scheduled for each postpartum patient and tracked using the log. Schedulers served as a patient navigator and scheduled both appointments. The nurse practitioners, physician, and midwife performed telehealth check‐in visits 1– 3 weeks postpartum. Providers used a four‐item checklist, created by the team, and placed the text in the summary of their notes. The four items included the EPDS, inquiring about breastfeeding and any issues, discussing the importance of postpartum visits, and asking about needs for community resources.

Intervention Results: The number of people who attended comprehensive postpartum visits increased to 56.8% (up from 27% prior to the intervention). The team performed a χ2 test of independence to determine the statistical significance of outcomes when compared with the baseline data. The outcome shows a statistically significant result, χ2(1, N=228) = 18.05, p=.000022. During the project, the balancing measure, team efficiency, improved as measured by anonymous surveys to team members.

Conclusion: Overall, this project proved to be low cost with high value for patients and the medical department. The initiative improved care by increasing attendance at comprehensive postpartum visits, identify- ing concerns early, detecting postpartum depression or anxiety in six patients, and identifying a surgical site infection during check‐in visits. The team's success would be intriguing to most practices that provide obstetrical care, given that the national postpartum return rate is only 60%. Recommendations for spread and sustainability include dedicated postpartum patient navigators, who would handle the schedule log, continuation of a check‐in visit, electronic EPDS, and ongoing staff education. Further study could show the efficacy of this model in other settings. Given the increased postpartum attendance and early identification of complications, the team successfully improved effective care to postpartum families in North Philadelphia.

Study Design: Quality improvement initiative

Setting: Einstein Medical Center, a large academic hospital in North Philadelphia

Population of Focus: Postpartum patients

Sample Size: 147 patients

Age Range: Childbearing age

Intervention Components (click on component to see a list of all articles that use that intervention): Telemedicine Systems (Hospital), Family-Based Interventions,

Intervention Description: NICU graduates require ongoing surveillance in follow-up clinics because of the risk of lower cognitive, motor, and academic performance. We hypothesized that multiple programmatic changes, including availability of telemedicine consultation before hospital discharge, would improve NICU follow-up clinic attendance rates. In this retrospective study, we included infants who survived and were premature (≤29 6/7 weeks/<1500 g) or had brain injury (grade III/IV intraventricular hemorrhage, stroke or seizure, hypoxic ischemic encephalopathy). We compared rates of follow-up for the early cohort (January 2018-June 2019; no telemedicine) with the late cohort (May 2020-May 2021; telemedicine available); and performed a mediation analysis to assess other programmatic changes for the late cohort including improved documentation to parents and primary care provider regarding NICU follow-up.

Intervention Results: The rate of successful 12-month follow-up improved from 26% (early cohort) to 61% (late cohort) (P < .001). After controlling for maternal insurance, the odds of attending a 12-month follow-up visit were 3.7 times higher for infants in the late cohort, for whom telemedicine was available (confidence interval, 1.8-7.9). Approximately 37% of this effect was mediated by including information for NICU follow-up in the discharge documentation for parents (P < .001).

Conclusion: Telemedicine consultation before NICU discharge, in addition to improving communication regarding the timing and importance of NICU follow-up, was effective at improving the rate of attendance to NICU follow-up clinics.

Study Design: Retrospective chart review

Setting: Children’s Hospital at a Medical Center in Maine with a level III NICU

Population of Focus: Infants who had been admitted to the NIC

Sample Size: 257 infants (152 infants were included in the early cohort, and 105 infants were included in the late cohort)

Age Range: Infants 0-12 months corrected age