The Use of Telemedicine to Address Disparities in Access to Specialist Care for Neonates

Abstract

Introduction: Outcomes for premature and critically ill neonates are improved with care provided by neonatologists in a neonatal intensive care unit (NICU). For smaller hospitals, maintaining the personnel and equipment necessary for the delivery and care of unexpectedly high-risk neonates is a significant challenge. To address this disparity in access, telemedicine has been increasingly used to support providers, patients, and their families in community newborn nurseries and NICUs. The purpose of this review is to present the current state of the use of telemedicine by regional NICUs to support community newborn nurseries, NICUs, and families.

Methods: A literature review was conducted by two independent reviewers. Articles were selected for inclusion if they described the use of telemedicine with neonates or in the NICU. Two reviewers assessed the quality of the articles using the National Heart, Lung, and Blood Institute Study Quality Assessment Tools.

Results: Fourteen articles were identified. After consensus discussion, eight of the articles were rated good and six were rated fair by the two reviewers. Many of the articles suggested improvements in quality of care, family satisfaction, and reductions in the cost of care. Unfortunately, a majority of the studies to date have had small sample sizes or were performed in a single institution and lacked robust evaluations of patient- and family-centered outcomes and provider decision making.

Conclusions: While these early studies are promising, more robust studies involving more patients and more institutions are needed to identify opportunities where telemedicine can impact health outcomes, patient-centeredness, or costs of care of neonates.

Introduction

Telemedicine has been used in both adult and pediatric care to provide connections between rural or community hospitals and larger regional medical centers. In studies where pediatric critical care physicians provided consultations to rural and underserved emergency departments without pediatric expertise, telemedicine consultations improved independently-assessed quality of care,¹ improved stabilization of patients,² shortened lengths of stay,³ reduced transfer rates,^4,5 and lowered overall costs.⁴ With similar models of regionalized care, it is likely that telemedicine consultations to mothers and neonates in rural and underserved urban communities could improve the quality of care provided in remote nurseries, including more effective newborn resuscitation, reduction of unnecessary neonatal transfers, and improved stabilization of critically ill neonates before transfer.

In 2014, the rate of preterm birth (infants delivered <37 completed weeks' gestation per 100 births) was 9.6%, and the low-birth-weight (<2,500 g) rate was 8.0%.⁶ Many of these newborns, as well as many full-term newborns with a variety of medical conditions, congenital anomalies, or perinatal complications, require specialist care in a neonatal intensive care unit (NICU).⁶ Sometimes these infants are born in hospitals without a NICU and, therefore, may require urgent stabilization and transport. Mortality and morbidity rates for premature and acutely ill newborns that require transport are higher than for those born at a hospital with a NICU.⁷ While there are ongoing efforts to have mothers carrying infants with prenatally identified risk factors deliver in hospitals with NICUs, sometimes the delivery of premature or ill infants occurs in hospitals not fully equipped to care for critically ill newborns.

Differences in access to neonatologists and expert neonatal care contribute to differences in outcomes and present opportunities for improvement in care. Given that NICUs are regionalized, telemedicine is an appealing modality for reducing health care disparities, particularly for rural and underserved communities that provide an essential community labor and delivery service. Telemedicine is currently used in a variety of ways in the care of newborns, including assessment of neonates in community hospitals during initial stabilization, to reduce unnecessary transfers, to reduce costs, and to improve family experience when infants are hospitalized in the NICU. Telemedicine is currently used in at least 29 NICUs throughout the United States.⁸ The purpose of this article is to review and describe the current uses of telemedicine in NICUs and provide insight into novel ways to leverage telemedicine technologies to improve the care of these patients.

Methods

The PubMed database was searched using the keywords “telemedicine” or “telehealth” combined with “neonatology,” or “neonate,” or “NICU”; “tele-neonatology” was searched independently. The reviewers also searched the reference lists of included articles for additional potential articles. Articles written in languages other than English, and studies on the use of telemedicine in retinopathy of prematurity assessment for preterm infants, screening for cyanotic congenital heart disease, obstetric interventions, breast feeding for healthy-term infants, and studies wherein the communication was limited to telephone only were excluded. Identified articles were reviewed using the National Heart, Lung, and Blood Institute (NHLBI) Study Quality Assessment Tools, developed jointly by methodologists from NHLBI and Research Triangle Institute International.⁹ This review tool was chosen because it has similar assessments over a variety of study types, including case series, case–control studies, observational cohort studies, cross-sectional studies, and controlled intervention studies, all of which were eligible for inclusion.

Results

Fourteen articles were identified and assessed for quality by two reviewers (H.S.F. and K.R.H.) who conducted reviews independently. The results of the quality assessment can be found in Table 1. The reviewers agreed on 12 of 14 assessments. Of those that were disagreed, one reviewer (H.S.F.) rated the studies as “good,” while the other (K.R.H.) rated them as “fair.” After discussion, reviewer 1 modified her assessment of Bell et al.¹⁰ from “good” to “fair,” and reviewer 2 modified her assessment of Yeo et al.¹¹ from “fair” to “good.” For the remaining 12 articles, 5 (41.7%) were rated as “fair” and the remaining 7 (58.3%) were rated as “good.” Primary concerns with the studies reviewed included low sample sizes, lack of adequate sample description, and lack of description or adjustment for confounders. The articles are described below under three categories: Neonatal Assessment, Quality and Cost of Care, and Patient- and Family-Centered Care.

Table 1.

Quality Assessment

STUDY	REVIEWER 1	REVIEWER 2	NOTES
Armfield et al.¹⁵	Fair	Fair	Conclusions drawn from retrospective analysis, no description of patients who received the intervention, so unable to determine if subjects are comparable, small sample size
Armfield et al.¹⁴	Fair	Fair	Very small sample size, no clear description of how sample was chosen, sample size that was selected for convenience/speed of completing study
Bell et al.¹⁰	Fair^a	Fair	Non-random sample, small sample (pilot study) but did show very good agreement for most variables
Fang et al.¹⁷	Good	Good	Observational study, fairly good response rate on survey
Fang et al.¹⁶	Fair	Fair	Low survey response rate (31.8%), homogenous study population, does not account for frequency of use
Garingo et al.¹²	Good	Good	No information about subject selection, very extensive list of observed variables
Garingo et al.¹⁸	Good	Good	No information about inclusion/exclusion or enrollment processes, well-executed study, hampered a bit by presence of rounding physicians in-person even in the telemedicine group
Gray et al.²⁵	Good	Good	Very nice study with randomization of groups to the interventions
Hall et al.²¹	Fair	Fair	No adjustment for cofounders, very little actual data in results section but did have large numbers, tried to control for maternal risks, insurance, race/ethnicity
Kim et al.²²	Good	Good	Short follow-up period, lack of confounders assessed, does not really account for maternal confounders in the rate of infants born at outlying nurseries
Makkar et al.²⁰	Good	Good	Well-defined population, did a nice job controlling for as many factors as possible in determining difference in length of stay
Robinson et al.²³	Good	Good	No discussion of sample size, little data on the follow-up rate
Wenger et al.¹³	Fair	Fair	Very small sample size
Yeo et al.¹¹	Good	Good^a	Small feasibility study using historical controls

After consensus discussion.

Neonatal Assessment

The value of telemedicine to assist in the assessment of neonates has been demonstrated in several studies. With respect to the feasibility and validity of evaluating and examining an infant over telemedicine, Garingo et al.¹² assessed 46 patients over 343 patient encounters, including physical examinations and data extraction from the patients' medical records. Of the 343 patient encounters, 304 were completed by a neonatologist at the bedside and a neonatologist over telemedicine, and 39 were completed by two neonatologists at the bedside. The authors found excellent to perfect agreements for many clinical variables, including patient identifying information, vital signs, real-time physiologic parameters (monitors and ventilator), degree of respiratory support, central lines, feeding tubes, level of activity, and genitourinary exam (κ range, 0.78–1.00). They also found intermediate to good agreement for subcostal retractions (κ = 0.49), but poor agreement for abdominal distention, capillary refill time, and assessments utilizing the electronic stethoscope for heart, breath, and bowel sounds (κ range, −0.01 to 0.36). Of note, they found similar agreement rates when assessments were completed by two in-person neonatologists, indicating that some of these characteristics may be subjective, and the disagreements may be due to provider interpretation, not the technology used to complete the assessments.¹²

Wenger et al.¹³ evaluated the feasibility of telemedicine to conduct neonatal dysmorphology and neurologic examinations. The study found that most abnormalities (>90%) could be accurately identified via telemedicine. However, the study had a small sample size (n = 20) and required a clinician to be at the bedside to assist in the examination. Another study by Armfield et al.,¹⁴ also with a small sample size (n = 8), assessed ventilated infants via telemedicine and in-person clinicians and found a 71% agreement overall in assessment. Telemedicine has also been studied by respiratory therapists to determine the feasibility of evaluation of ventilator-derived parameters and patient-derived parameters in neonates. The authors found that telemedicine is reliable for the assessment of easily visualized, preprogrammed parameters for mechanically ventilated neonates such as pressure control and breathing frequency (r = 1.0) but less reliable for other ventilator variables such as inspiratory-expiratory ratio (r = 0.47).¹⁰

Quality and Cost of Care

Data on the clinical usefulness and cost-effectiveness of telemedicine providing the virtual presence of a neonatologist in a labor and delivery unit, newborn nursery, or community NICU remain limited. However, early evidence indicates that telemedicine can be used after deliveries to keep newborns in their communities. Armfield et al.¹⁵ evaluated the cost and potential savings of telemedicine in an observational study at a tertiary perinatal center and four remote hospitals without regionalized NICUs. They found that among 19 telemedicine consultations over the course of 12 months, 5 patients, confirmed by independent assessment, were able to safely remain in their community and avoided transport to the tertiary center after the use of telemedicine. The reduction in transfers translated to a savings of 54,400 Australian dollars, or ∼41,000 US dollars across all five patients.¹⁵

Fang et al. helped implement a telemedicine program that connected an academic medical center to six newborn nurseries (level I and II NICUs) within the same health system located 40–120 miles from the main medical center. They evaluated this program both qualitatively¹⁶ and quantitatively.¹⁷ Through an electronic survey, they found that 90.3% of respondents believed that teleneonatology enhanced communication between sites, and 84.9% believed that teleneonatology ensured standardization of care across sites. Most respondents found the technology easy to use (90.2%) and well integrated into the workflow (78.0%). They also found that 45% of respondents thought that there were times when teleneonatology could have been used but was not.¹⁶ Through focus groups in the same study, Fang et al.¹⁶ found that teleneonatology benefited the care time by reducing rates of newborn transfer and instilling confidence, providing reassurance, and easing anxiety among providers. Quantitatively, Fang et al.¹⁷ found that over the course of 33 months, 32% of neonates were able to remain at the referring hospital, and providers believed that telemedicine improved teamwork (86%) and improved patient safety and quality of care (93%).¹⁷

Garingo et al.¹⁸ assessed the feasibility and acceptability of a tele-rounding model in an academic-affiliated community hospital NICU. Patients were assigned to an onsite or offsite neonatologist, while the remainder of the team (fellows, residents, nurses) remained the same for all patients. The first 20 patients enrolled were randomized to receive either an onsite or offsite neonatologist. The next 20 patients enrolled were matched to the first 20 based on clinical characteristics (gestational age, birth weight, diagnoses, and disease severity) and received the other type of neonatologist from the patient they matched. Patients were followed for their entire stay, and there were a total of 373 patient encounters (197 in the control group and 176 in the telemedicine group). Of the encounters completed by the offsite neonatologist, there was no need for the onsite neonatologist to intervene emergently or urgently. They found no differences in length of stay, hospital charges, days of antibiotics, or the number of radiologic studies completed.¹⁸

After establishing a level II NICU in Oklahoma utilizing 24/7 nurse practitioners, telemedicine, and neonatologists in-house 3 days per week,¹⁹ Makkar et al.²⁰ studied the treatment outcomes of late-premature infants (32–35 weeks) admitted to the regional level II NICU (n = 87) compared with a control group of geographically similar patients admitted to a level IV NICU (n = 56). They found that patients at the level II NICU with access to telemedicine had shorter lengths of stay by 2.23 days, reached full enteral feeds sooner, and had fewer days on noninvasive ventilation and supplemental oxygen.²⁰

Telemedicine has also been used to involve regionalized expertise before delivery in combined perinatal-neonatal programs. Two studies to date have published their experiences with such a model. The first, by Hall et al.,²¹ utilized a rural telemedicine network to connect neonatal and maternal-fetal medicine subspecialists at the academic medical center to patients and their community physicians regarding high-risk conditions. This network also had clinical guidelines and protocols to support evidence-based management and referral. They found that low-birth-weight infants, especially those born to uninsured or Medicaid-insured mothers living further away from the academic medical center, were more likely to be born at the academic medical center after the implementation of the telemedicine program.²¹ Another study²² found that after the introduction of an obstetric and neonatal telemedicine program at hospitals without NICUs, the percentage of very-low-birth-weight (<1,500 g) neonates delivered at those hospitals decreased from 13.1% to 7.0% (p = 0.01) and was associated with a concurrent decrease in infant mortality statewide.²²

The use of telemedicine after discharge has also been shown to decrease emergency hospital visits. Robinson et al.²³ used telemedicine visits to supplement visits with a neonatal nurse three times a week after discharge. Infants randomized to receive telemedicine visits received both the control in-person visits three times a week and video visits with a neonatal nurse after discharge. Infants in the telemedicine and control arms had the same number of scheduled visits with a nurse. However, the infants in the telemedicine arm had significantly fewer emergency visits to the hospital after discharge. Parents who received telemedicine were also more likely to have more scheduled visits than they needed, suggesting that fewer visits may be adequate when telemedicine support is used.²³

Patient- and Family-Centered Care

Telemedicine technologies have also been shown to improve patient- and family-centered care with resulting satisfaction of families of hospitalized children both before transport, during hospitalization, and after discharge.^1,4,24 The previously described study by Garingo et al.¹⁸ found that parents were very comfortable with a model of a remote attending performing daily NICU rounds by telemedicine, though the survey had a low response rate (45%).¹⁸ Another study by Yeo et al.¹¹ assessed the feasibility and acceptance of a telemedicine program to have the families of hospitalized infants connect to infants hospitalized in the NICU. Among 46 NICU patients and their families, the authors found 100% satisfaction with the program, and 97% of families expressed confidence in the safety and security of online video access.¹¹ In Sweden, 74% of families randomized to telemedicine in addition to home health visits (compared with home health visits alone) after discharge from the NICU found video calls to be more helpful than phone calls. Families found the video calls to be easy to use (95% of families rating as easy or very easy) and important to the neonate's care (28% reporting as important and 20% as very important). However, this study was conducted in an environment where home health visits are already provided. Finally, a randomized control trial by Gray et al.²⁵ found that NICU patients randomized to receive virtual visits and distance learning, both while they were admitted and after discharge, resulted in significant improvements in family satisfaction and family perception of the quality of care, compared with patients who received standard care without the use of telemedicine.

Discussion

Our review of the literature suggests several use cases to the utilization of telemedicine in the care of neonates. The published benefits are related to remote neonatal assessments, improved or non-inferior quality to in-person care, reductions in cost of care, and high measures of patient- and family-centered care. In particular, the studies by Garingo et al.¹² and Wenger et al.¹³ provide evidence that telemedicine can be used clinically outside of the research setting, and its use results in acceptable clinical evaluations of key components of the physical exam. Because telemedicine technology is rapidly developing, further studies are needed to determine if newer technologies can provide even better evaluations and can be used in more clinical care models outside of research. Studies evaluating teleneonatology also suggest its ease of use by providers¹⁶ and increased provider confidence.¹⁷ The studies of quality of care provided to neonates via telemedicine either found no clinical difference in outcomes for patients seen via telemedicine,¹⁸ or improved outcomes related to length of stay, time to full enteral feeds, and fewer days on supplemental oxygen.²⁰ Telemedicine was shown to reduce transfers to higher levels of care and reduce the costs associated with transfers. However, there is a need for further study into health care savings by means of using telemedicine in the NICU, particularly in the United States.

While the studies described above provide an early signal of the benefits of using telemedicine in the care of neonates, further studies are needed with emphasis on the role of telemedicine in reducing health disparities for rural and urban underserved neonates. Assessment of benefits to parents and families associated with the ability to connect to the bedside of their neonate via telemedicine, regardless of where the parent and family are located, is also needed. Early work in this area has been encouraging.^26,27 Families have reported high rates of satisfaction with telemedicine in numerous studies,^11,18,25 but further study is needed on patient care outcomes such as length of stay, parental confidence and bonding, breastfeeding rates, effect of telemedicine on bedside visitation, confidence in care providers, parental anxiety, and parental knowledge about their infant's condition.

Beginning a telemedicine program at any site has large upfront costs, and maintaining a successful system requires experienced technical personnel to troubleshoot issues that may arise. One option to reduce costs is to partner with a hospital with telemedicine experience, which could provide technical support remotely, and may also provide telemedicine equipment as part of a service agreement. However, early studies have shown cost savings by referring hospitals after a telemedicine program has been established, due to more neonates remaining at their home hospitals.¹⁵ In the future, as the availability of telemedicine becomes more widespread, families may choose hospitals that have this technology, which may offset the cost of telemedicine.

This study is not without limitations. The study was not designed as a comprehensive systematic review and does not include unpublished data from conferences or articles from journals not indexed in the PubMed database. Because we excluded studies on the use of telemedicine in retinopathy of prematurity assessment for preterm infants, screening for cyanotic congenital heart disease, or obstetric interventions, our evaluation may be incomplete. We also focused on newborn infants and did not include the use of telemedicine in the emergency department where it is sometimes used to assist in the care on neonates <30 days of age. Finally, because the use of telemedicine overall, and especially in pediatrics, is rapidly changing, new innovations in technology may not be included here.

Conclusions

Telemedicine provides unique opportunities for remote specialist and neonatologist expertise to improve the quality of care, increase patient/family-centeredness of care, and reduce overall health care costs. Parents appear to be accepting telemedicine and are appreciative of opportunities to view their infants and participate in the care plan. While a number of studies have suggested benefits of telemedicine in NICUs and newborn nurseries, only 29 (∼3%) NICUs currently offer telemedicine.⁸ There is much to be learned about the significance of large-scale adoption of neonatal telemedicine, particularly in its potential to improve care for neonates in rural and underserved urban settings and its value in the stabilization of critically ill infants before transfer to higher-level NICUs. Larger, multi-institutional trials with diverse patient populations assessing the impact of telemedicine on health outcomes, length of hospital stay, and family satisfaction will have tremendous potential for improving the care of premature and critically ill neonates—the vulnerable population in which quality of care has the greatest potential to improve quality-adjusted life years.

Footnotes

Acknowledgment

This work was supported through an award from the University of California Office of the President.

Disclosure Statement

No competing financial interests exist.

References

Dharmar

, Romano

, Kuppermann

, et al. Impact of critical care telemedicine consultations on children in rural emergency departments. Crit Care Med, 2013; 41:2388–2395.

Dayal

, Hojman

, Kissee

, et al. Impact of telemedicine on severity of illness and outcomes among children transferred from referring emergency departments to a children's hospital PICU. Pediatr Crit Care Med, 2016; 17:516–521.

Lopez-Magallon

, Otero

, Welchering

, et al. Patient outcomes of an international telepediatric cardiac critical care program. Telemed J E Health, 2015; 21:601–610.

Yang

, Dharmar

, Yoo

, et al. Economic evaluation of pediatric telemedicine consultations to rural emergency departments. Med Decis Making, 2015; 35:773–783.

Labarbera

, Ellenby

, Bouressa

, Burrell

, Flori

, Marcin

. The impact of telemedicine intensivist support and a pediatric hospitalist program on a community hospital. Telemed J E Health, 2013; 19:760–766.

Murphy

, Mathews

, Martin

, Minkovitz

, Strobino

. Annual summary of vital statistics: 2013–2014. Pediatrics, 2017; 139:e20163239.

Phibbs

, Baker

, Caughey

, Danielsen

, Schmitt

, Phibbs

. Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants. N Engl J Med, 2007; 356:2165–2175.

Olson

, McSwain

, Curfman

, Chuo

The current pediatric telehealth landscape. Pediatrics, 2018. [Epub ahead of print]; pii:peds.2017-2334. doi: 10.1542/peds.2017-2334.

NHLBI Study Quality Assessment Tools. U.S. Department of Health and Human Services. Available at www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools (last accessed May 17, 2018 .)

10.

Bell

, Yager

, Clark

, et al. Telemedicine versus face-to-face evaluations by respiratory therapists of mechanically ventilated neonates and children: A pilot study. Respir Care, 2016; 61:149–154.

11.

Yeo

, Ho

, Khong

, Lau

. Virtual visitation in the neonatal intensive care: Experience with the use of internet and telemedicine in a tertiary neonatal unit. Perm J, 2011; 15:32–36.

12.

Garingo

, Friedlich

, Tesoriero

, Patil

, Jackson

, Seri

. The use of mobile robotic telemedicine technology in the neonatal intensive care unit. J Perinatol, 2012; 32:55–63.

13.

Wenger

, Gerdes

, Taub

, Swarr

, Deardorff

, Abend

. Telemedicine for genetic and neurologic evaluation in the neonatal intensive care unit. J Perinatol, 2014; 34:234–240.

14.

Armfield

, Bensink

, Donovan

, Wootton

. Preliminary evaluation of a system for neonatal teleconsultation. J Telemed Telecare, 2007; 13:4–9.

15.

Armfield

, Donovan

, Bensink

, Smith

. The costs and potential savings of telemedicine for acute care neonatal consultation: Preliminary findings. J Telemed Telecare, 2012; 18:429–433.

16.

Fang

, Asiedu

, Harris

, Carroll

, Colby

. A mixed-methods study on the barriers and facilitators of telemedicine for newborn resuscitation. Telemed J E Health, 2018; 24:811–817.

17.

Fang

, Collura

, Johnson

, et al. Emergency video telemedicine consultation for newborn resuscitations. Mayo Clin Proc, 2016; 91:1735–1743.

18.

Garingo

, Friedlich

, Chavez

, et al. “Tele-rounding” with a remotely controlled mobile robot in the neonatal intensive care unit. J Telemed Telecare, 2016; 22:132–138.

19.

McCoy

, Makkar

, Foulks

, Legako

. Establishing level II neonatal services in southwestern Oklahoma. J Okla State Med Assoc, 2014; 107:493–496.

20.

Makkar

, McCoy

, Hallford

, Escobedo

, Szyld

. A hybrid form of telemedicine: A unique way to extend intensive care service to neonates in medically underserved areas. Telemed J E Health, 2018; 24:717–721.

21.

Hall

, Hall-Barrow

, Garcia-Rill

. Neonatal regionalization through telemedicine using a community-based research and education core facility. Ethn Dis, 2010; 20:S1-136–S1-140.

22.

Kim

, Teague-Ross

, Greenfield

, Keith Williams

, Kuo

, Hall

. Telemedicine collaboration improves perinatal regionalization and lowers statewide infant mortality. J Perinatol, 2013; 33:725–730.

23.

Robinson

, Gund

, Sjöqvist

, Bry

. Using telemedicine in the care of newborn infants after discharge from a neonatal intensive care unit reduced the need of hospital visits. Acta Paediatr, 2016; 105:902–909.

24.

Yager

, Clark

, Cummings

, Noviski

. Parent participation in pediatric intensive care unit rounds via telemedicine: feasibility and impact. J Pediatr, 2017; 185:181.e3–186.e3.

25.

Gray

, Safran

, Davis

, et al. Baby CareLink: Using the internet and telemedicine to improve care for high-risk infants. Pediatrics, 2000; 106:1318–1324.

26.

Children's Miracle Networ NI CU webcams assist families far from home—UC Davis Children's Hospital. Available at: https://www.youtube.com/watch?v=Jccblc9xRho (last accessed July 23, 2018 ).

27.

UC Davis NICU Live Cam. Good Day Sacramento, 2017. Available at: https://gooddaysacramento.cbslocal.com/video/3682222-uc-davis-nicu-live-cam/ (last accessed July 23, 2018 ).