August 27, 2020
N Engl J Med 2020; 383:883-884
DOI: 10.1056/NEJMc1913719
TO THE EDITOR:
Rural and indigenous populations are disproportionately affected by cardiovascular disease,1,2 with a higher prevalence of cardiovascular risk factors than urban populations, as well as harsher environmental conditions, reduced access to services, and greater difficulty in attracting and retaining health professionals.3,4 Patients therefore wait longer and travel larger distances to access diagnostic services, or they forgo treatment.
We compared waiting and reporting times and patient travel distances for exercise stress testing and 24-hour Holter monitoring over 12-month periods before (retrospective analysis) and after (prospective analysis) implementation of a telemedicine program (Tele-Cardiac Investigations) in two rural and remote regions in Australia with a referral population of 44,400 and a geographic area of 696,650 km2.
The telemedicine program enabled cardiology specialists at a metropolitan location (Royal Brisbane and Women’s Hospital [RBWH]) to work with local staff to conduct exercise stress tests and Holter monitoring remotely at 11 facilities (see the Supplementary Appendix, available at NEJM.org). For exercise stress testing, a live video feed of the electrocardiographic monitor at the rural facility allowed the telemedicine team to view patient data in real time. Local staff performed the exercise stress test with guidance from the telemedicine team, or, alternatively, the exercise stress test system was remotely controlled by the telemedicine team. The test results were immediately reported by the telemedicine team with the use of remote access software. For Holter monitoring, rural staff applied the device with guidance from the telemedicine team. The telemedicine team then remotely accessed the initialization software to program and start the recording. After the recording was complete, the telemedicine team remotely transferred the data to analysis software at RBWH for reporting.Table 1.
Effect of Implementation of Telemedicine for Cardiac Testing.
Implementation of the telemedicine program was associated with a 42% increase in the number of tests performed over 12 months (516 in the 12 months before implementation vs. 734 in the 12 months after), with an even greater proportional increase in the number of patients from indigenous populations undergoing testing (63 before implementation vs. 127 after implementation) (Table 1). There were substantial reductions in waiting times to have tests conducted (17.71 fewer days [44.6% reduction]) and to have results reported (35.82 fewer days [99.2% reduction]), resulting in a significant reduction in the total time from referral to reporting (56.66 fewer days [71.1% reduction]; P<0.001). Round-trip travel was reduced by 502 km per patient, on average, for patients requiring Holter monitoring, with telemedicine allowing 91.3% of patients to receive testing without having to travel away from their local health facilities.
Adam C. Scott, Ph.D.
Alice McDonald, G.Dip.Cardiac.
Tiffany Roberts, B.E.S.S.
Curtis Martin, B.E.S.S.
Timothy Manns, B.E.S.S.
Meghan Webster, B.E.S.S.
Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
adam.scott@health.qld.gov.au
David Walker, M.B., B.S.
Longreach Hospital, Longreach, QLD, Australia
Alan Sandford, M.B., B.S.
Mount Isa Hospital, Mount Isa, QLD, Australia
Paul Scuffham, Ph.D.
Griffith University, Brisbane, QLD, Australia
John J. Atherton, Ph.D., M.B., B.S.
Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia