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Original Investigation |

Impact of an Intensive Care Unit Telemedicine Program on Patient Outcomes in an Integrated Health Care System

Boulos S. Nassar, MD, MPH1,2; Mary S. Vaughan-Sarrazin, PhD1,3; Lan Jiang, MS1; Heather S. Reisinger, PhD1,3; Robert Bonello, MD4; Peter Cram, MD, MBA3,5,6
[+] Author Affiliations
1Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
2Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City
3Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City
4Division of Pulmonary and Critical Care Medicine, Minneapolis VA Health Care System, Minneapolis, Minnesota
5Department of Internal Medicine, University of Toronto, Toronto, Ontario, Canada
6Division of General Internal Medicine, Mt Sinai/University Health Network Hospitals, Toronto, Ontario, Canada
JAMA Intern Med. 2014;174(7):1160-1167. doi:10.1001/jamainternmed.2014.1503.
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Importance  Intensive care unit (ICU) telemedicine (TM) programs have been promoted as improving access to intensive care specialists and ultimately improving patient outcomes, but data on effectiveness are limited and conflicting.

Objective  To examine the impact of ICU TM on mortality rates and length of stay (LOS) in an integrated health care system.

Design, Setting, and Participants  Observational pre-post study of patients treated in 8 “intervention” ICUs (7 hospitals within the US Department of Veterans Affairs health care system) during 2011-2012 that implemented TM monitoring during the post-TM period as well as patients treated in concurrent control ICUs that did not implement an ICU TM program.

Intervention  Implementation of ICU TM monitoring.

Main Outcomes and Measures  Unadjusted and risk-adjusted ICU, in-hospital, and 30-day mortality rates and ICU and hospital LOS for patients who did or did not receive treatment in ICUs equipped with TM monitoring.

Results  Our study included 3355 patients treated in our intervention ICUs (1708 in the pre-TM period and 1647 in the post-TM period) and 3584 treated in the control ICUs during the same period. Patient demographics and comorbid illnesses were similar in the intervention and control ICUs during the pre-TM and post-TM periods; however, predicted ICU mortality rates were modestly lower for admissions to the intervention ICUs compared with control ICUs in both the pre-TM (3.0% vs 3.6%; P = .02) and post-TM (2.8% vs 3.5%; P < .001) periods. Implementation of ICU TM was not associated with a significant decline in ICU, in-hospital, or 30-day mortality rates or LOS in unadjusted or adjusted analyses. For example, unadjusted ICU mortality in the pre-TM vs post-TM periods were 2.9% vs 2.8% (P = .89) for the intervention ICUs and 4.0% vs 3.4% (P = .31) for the control ICUs. Unadjusted 30-day mortality during the pre-TM vs post-TM periods were 7.7% vs 7.8% (P = .91) for the intervention ICUs and 12.0% vs 10.2% (P = .08) for the control ICUs. Evaluation of interaction terms comparing the magnitude of mortality rate change during the pre-TM and post-TM periods in the intervention and control ICUs failed to demonstrate a significant reduction in mortality rates or LOS.

Conclusions and Relevance  We found no evidence that the implementation of ICU TM significantly reduced mortality rates or LOS.

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Figures

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Figure 1.
Flow Diagrams for Generation of Final Analytical Cohorts

Flow diagrams outlining the selection process and generation of the final analytical cohorts. ICU indicates intensive care unit.

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Figure 2.
Adjusted Intensive Care Unit (ICU) Mortality Rates for Intervention and Control ICUs During Pretelemedicine and Posttelemedicine Periods

Colors and pairs correspond to individual ICU-level data provided in eTable 2 in the Supplement.

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Figure 3.
Adjusted 30-Day Mortality Rates for Intervention and Control Intensive Care Units (ICUs) During Pretelemedicine and Posttelemedicine Periods

Colors and pairs correspond to individual ICU-level data provided in eTable 2 in the Supplement.

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