Procedure of using Personal Protective Equipment (PPE) during COVID-19

Introduction

Coronavirus disease 2019 (COVID-19) has been announced as epidemic by the World Health Organization, later it declared as a pandemic on 12th March of 2020, with Italy being considered the fresh ‘‘epicentre’’ of the emergency, which started in the province of China, Wuhan. 22,512 cases have been accounted for in Italy when begins from 15 March 2020, 2,026 (9%) of which belong to people who works in hospitals [1]. Tragically, rates for emergency unit with the requirement for mechanical ventilation and tracheal intubation and are roughly 5% in patients having Corona Virus [2]. Given the fast development of this outburst and the need to bound death rate in medical care laborers, it is principal that medical services experts be comfortable with mutually the meaning of an excessive hazard introduction and the right donning & doffing methods for the PPE required throughout the consideration of these infectious people. A great hazard introduction has been characterized as ‘’delayed near interaction with Corona virus patients who are not using mask whereas the medical services specialist’s mouth and nose are presented to objects conceivably contaminated with the infection [3].

At the point when medical services suppliers’ mouth, nose or eyes are insecure during the lead of airborne creating clinical methodology on patients with Corona disease (e.g., Nebulizer therapy, Cardiopulmonary resuscitation, intubation, extubation and bronchoscopy) around is a great danger of infection [3]. At the point when utilized effectively, PPE shields from this Virus, yet this is basic that PPE is appropriately donned and properly doffed. The breadth and variety of different types of PPE, such as facemasks, gloves, and respiratory equipment, as well as the extended use beyond previous standards, have led to a spectrum of common dermatologic conditions, including contact/irritant dermatitis, pressure-related skin injury, acneiform eruptions, and moistureassociated skin irritation [4]. These reenactments have uncovered basic parts of the cycle that, whenever done inappropriately, may prompt penetrates in biosafety and possible risk with the infection, triggering Corona infection.

Donning

Mask: Mask N95 is suggested. Mask quality examination must perfectly be done be acted ahead of time, as right face mask and size are expected to guarantee an appropriate seal. Facial hair at the face-mask interface advances seal spillage and may diminish security [5].

Gloving: In spite of the fact that not should have been sterile, consistently utilize expanded sleeve gloves. Guaranteeing that the most distal piece of the outfit’s sleeve is protected cozily by the glove is vital to forestalling hand and lower arm infection.

Time Managing PPE ought to be worn appropriately; this ought to be done cautiously and never be surged. This may mean a postponement in giving consideration in code blue/airway organization reaction times.

Doffing

Removing of Gloves: These are viewed as the supreme polluted piece of PPE in the wake of playing out a high danger clinical procedure. Evacuation of the main glove is normally simpler than the subsequent one. While eliminating the subsequent glove, guarantee that there is as negligible interaction as conceivable between the sleeve of the and the un-gloved hand/fingers and gloved hand. Try not to snap of gloves.

Eliminating Gown: This is the most 2nd infectious PPE component. Guarantee that uncovered hands don’t contact the front of the gown while eliminating. A careful outfit that can be pulled off without untying it might present extra security.

Eliminating Mask: Continuously try not to contact the anterior of the mask (and additionally face shield) with the hands while eliminating. Keeping up pressure on the inferior strap is valuable for forestalling snapping while at the same time eliminating. The hand cleanliness with alcohol-based sanitizers be done for 15–20 sec after each item of Protective Personal Equipment is doffed to guarantee total expulsion of infection pollution from hands.

Conclusion

The right utilization of Protective Personal Equipment is important to diminish the quantity of contaminated medical services laborers caring about patients with Corona Virus. We trust that featuring a portion of these basic parts of wearing/doffing of PPE will bring down the likelihood of experiencing biosafety breaches, at last converting into a smaller sickness trouble between medical care laborers caring about Corona Virus patients.

 

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Frank’s Sign as a Predictor of Cardiovascular Disease

Introduction

Cardiovascular disease for many years has represented the leading cause of hospitalization and death worldwide. More people die each year from cardiovascular disease (CVD) than from any other cause. Heart disease includes a wide variety of diseases that affect the heart: blood vessel disease, coronary artery disease, arrhythmias, congenital heart defects, heart valve disease, heart muscle disease, and heart muscle infections. The risk of suffering from cardiovascular disease (CVD) is increased by an unhealthy diet, which is characterized by a low consumption of fruits and vegetables and a high consumption of salt, sugars and fats. An unhealthy diet contributes to obesity and being overweight, which in turn are risk factors for CVD. Ischemic heart disease is the most common coronary heart disease, in general it refers to those conditions that involve the narrowing or blockage of blood vessels, caused by damage to the heart or by underlying pathologies such as atherosclerosis that represents a large rate of morbidity.

It is defined as the accumulation of fatty plaque that thickens and hardens on the arterial walls that usually inhibits the flow of blood through the arteries to organs and tissues, of an asymptomatic initial stage, silent evolution and that occurs with sudden death. Among the markers of atherosclerosis, we find the Frank’s sign or diagonal groove of the earlobe, also associated with cardiac pathologies such as obstructive ischemic heart disease, cerebrovascular accident, among other coronary problems. Symptoms of cardiovascular disease can be different between men and women, and symptoms can include chest pain (angina), shortness of breath, pain, numbness, weakness, or cold in the legs or arms if they narrow the blood vessels of the parts in the body, pain in the neck, jaw, throat, upper abdomen, or back. Some of the risk factors for developing heart disease can include age, gender, family history, smoking, poor diet, lack of physical activity, alcohol consumption, hypertension, diabetes, and obesity.

Materials and Methods

A bibliographic search was carried out that spanned from 2017 to 2021 in the databases pubmed, Elsevier, scielo, Update, medline, national and international libraries. We use the following descriptors: Frank’s sign, cardiovascular disease, heart disease, diagonal groove of the earlobe. The data obtained oscillate between 16 and 60 records after the use of the different keywords. The search for articles was carried out in Spanish and English, it was limited by year of publication and studies between 2017 and 2021 were used. The main exclusion criteria were articles that had more than 5 years of publication.

Results

Frank’s sign is defined as an anatomical accident that is structurally characterized by an accumulation of collagen fibers that make up a large conjunctive septum that leaves fat clusters without septum, with a superficial capillary plexus of low density, forming a cleft diagonal that begins at the lower edge of the external auricular canal and is directed at an angle of 45° towards the edge of the ear lobe [1]. This anatomical accident is observed in more than half of the adult population in both sexes, it is generally complete, bilateral, deep and is accompanied by accessory furrows, with the age of the patient its prevalence increases significantly and its morphological characteristics are accentuated. In relation to modifiable cardiovascular risk factors, the bilateral Frank’s sign is significantly more prevalent in patients with a history of cardiovascular event than in patients without a history [2].

Atrial lobe cleft is more prevalent after age 50 and is associated with obesity, smoking, and high blood pressure. A genetic basis related to the HLA-B27 system, the C3-F gene for atherosclerosis, and chromosome 11 [3]. Several studies have confirmed the relationship between the cleft lobe sign, cardiovascular disease and ischemic heart disease, which have shown a higher incidence in Caucasian, Chinese and Latino populations and a lower incidence in the Japanese population [3,4]. The pathophysiology is not very clear, but the pathophysiological link between Frank’s sign and coronary artery disease has been difficult to determine. Anatomically, both the earlobe and the heart are supplied by terminal arteries and without the possibility of collateral circulation, this being a hypothesis. Another suggestion is that the generalized loss of elastin and elastic fibers seen in men by biopsy taken from the earlobes of affected individuals reflects microvascular disease that is also present in the coronary bed [4,5].

Discussion

In 1973 the American pulmonologist Saunsders T. Frank described the diagonal furrow of the earlobe (Frank’s sign) and called it a potential marker of cardiovascular disease. 48 years later, its usefulness continues to generate controversy, the studies published to date remain inconsistent and with disparate results [6]. According to a large epidemiological study directed by Tranchesi in a population of patients with ischemic heart disease compared to healthy controls, the cleft lobe sign is related to the number of damaged coronary vessels with obstruction greater than 70% (p = 0.015), with a sensitivity of 65%, specificity of 72%, positive predictive value of 42%, and negative predictive value of 87% [7].

The most recent study is that of Marta Aligisakis et al, made in Switzerland, with 5064 patients being published in 2016; The objective of this study was to evaluate the associations of Frank’s sign with a large panel of cardiovascular risk factors and also with cardiovascular diseases in a sample based on the adult population; finding as a result that Frank’s sign is significantly associated with hypertension and a history of cardiovascular disease, independently of other risk factors or potential confounding factors; Within the results, he comments that it is more prevalent in men and that it increases with age and that a possible explanation is the changes in collagen due to aging and smoking. The Frank sign also presented associations between hypertension, glucose level and the history of coronary disease that remained significant after adjusting for body mass index, it also suggests that this sign could be used as a marker of these risk factors [6-10].

Conclusion

The cardiovascular risk calculated based on contrasted predictive indices (Framingjan equations, REGICOR, SCORE, ASCVD), is significantly higher in patients who have shown diagonal earlobe Swedish (FRANK’S SIGN), especially when it is complete, bilateral, deep and meets accessory grooves. Which leads us to affirm that this anatomical accident should be considered an indicator of cardiovascular risk associated with the natural history of the patient with risk factors for cardiovascular disease and the existence of a history of the same events.

 

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Is Pentraxin 3 A Marker in Pathogenesis of Metabolic Syndrome

Editorial

Pentraxin 3 (PTX3) is an acute-phase protein that is structurally similar to C-reactive protein (CRP). Macrophages, endothelial cells, and adipocytes all produce PTX3 in response to inflammatory stimuli, but hepatocytes are the main source of CRP. PTX3 could play a role in the genesis of obesity, metabolic syndrome (MetS), and CRP because obesity and MetS are chronic inflammatory diseases [1]. MetS is a group of risk factors that includes glucose intolerance, abnormal lipid profiles, hypertension, and abdominal obesity [2- 6]. Each of these factors has been linked to atherosclerosis and cardiovascular disease. The majority of current research has found a link between MetS components and inflammatory mediators such as interleukin-6, tumor necrosis factor-α, and CRP [7]. Furthermore, serum CRP levels were shown to be greater in individuals with more risk factors for MetS, and higher serum CRP levels were related to higher occurrence of cardiovascular events, reflecting the prognostic relevance of MetS severity [8]. In particular, many types of cells, including macrophages, dendritic cells, neutrophils, adipose cells, fibroblasts, and vascular endothelial cells, have been reported to produce PTX-3, a newly recognized acute-phase reactant that is structurally and functionally similar to CRP [9]. The link between MetS and PTX-3 hasn’t been well investigated, and the available evidence appears to be discordant. Several investigations have found a link between MetS components and inflammatory mediators such as interleukin-6, tumor necrosis factor-α, and CRP [7]. The hs-CRP is the most well-known and validated of these inflammatory biomarkers. Insulin resistance, endothelial dysfunction, and unfavorable cardiovascular events have all been linked to high levels of hs-CRP [10,11].

The level of plasma PTX3 was found to be inversely related to metabolic syndrome, overweight/obesity, and dyslipidemia-related parameters, implying that PTX3 may have a cardioprotective role in atherosclerosis [12]. Obese people have dysregulated circulating PTX3 levels, which are raised after acute aerobic activity. In patients with CVD, high-intensity interval exercise (HIIE) has been shown to be equally beneficial as continuous moderate-intensity exercise in increasing endothelial function, as measured by BAFMD (brachial artery flow-mediated dilation) [13]. In obese people, HIIE could be used as a time-saving exercise prescription technique to enhance endothelial function in the short term, even if plasma PTX3 levels are elevated [13]. Another, the presence of elevated PTX-3 levels in the blood is linked to intermediate to severe obstructive sleep apnea syndrome [14]. For sleep apnea syndrome research, the PTX-3 biomarker appears to be a promising option [14]. Because high-quality technical diagnostic and treatment equipment, as well as highly-educated and experienced staff, sleep apnea syndrome is associated with considerable cardio-, cerebrovascular, metabolic, and hormonal comorbidities, it is one of the more expensive medical specialty [14].

Patients with type 2 diabetes (T2D) are more likely to develop nonalcoholic fatty liver disease (NAFLD). PTX3 is an inflammatory marker and a cardiovascular risk factor, as said. In patients with T2D, PTX3 is linked to TC, TG, LDL-C, apo B, and apo C3. Only in NAFLD patients do associations with LDL-C and apolipoproteins persist. The findings of our study could help us better understand the factors that influence PTX3 in T2D patients and, as a result, provide more tailored treatment [15]. PTX3 seems to be an unique therapy target for GLP-1RAs, a pharmacological family that has the potential to bridge the gap between T2D and NAFLD while also preventing cardiovascular disease (on a primary or secondary basis). In addition to explicate this logical and intriguing theory, prospective human trials using GLP-1RAs in patients with T2D and NAFLD, examining their influence on PTX3, are needed [16]. This could be a key component of tailored treatment for individuals with T2D, NAFLD, or cardiovascular disease who want to improve their prognosis. PTX3 could be a useful biomarker and therapy target for GLP-1RAs in this scenario [17]. The presence of PTX-3 was linked to the severity of MetS, as well as other inflammatory markers and cardiovascular testing [18]. Pentraxin 3 could be a precursor to cardiovascular disease in children who are overweight too [19]. Therefore, the level of PTX3 in a child’s blood can be used to measure cardiovascular risk, allowing for early intervention and prevention of future cardiovascular disorders [20]. Future longitudinal studies are needed to evaluate the predictive value of pentraxin 3 for MetS. However, the mechanisms and therapeutic potential of PTX3 in MetS remained to be investigated.

 

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Three-Dimensional Printed Mold for Neovaginal Cavity Maintenance in Vaginal Agenesis: A Case Report

Introduction

Vaginal agenesis is one of the most common congenital anomalies of the female genital tract, occurring in 1 out of 5,000 to 10,000 live born females [1]. It may present either as an isolated developmental defect or within a complex of other anomalies and is commonly associated with Mayer Rokitansky Küster Hauser syndrome. Several surgical methods for vaginal reconstruction have been introduced in the literature [2], and various attempts have been made to achieve reconstruction without constriction. Of these methods, McIndoe vaginoplasty is a widely accepted procedure. The correction of vaginal agenesis requires the creation of a neovaginal cavity that is dissected between the bladder and the rectum. After surgical reconstruction of a vagina, long term application of a vaginal mold is necessary to maintain the neovaginal space and to prevent contraction [3]. We present a case of non-syndromic agenesis of the lower vagina in an 18 year old girl and its post-surgical management using a three-dimensional (3D) printed thermoplastic polyurethane (TPU) vaginal mold.

Case Report

An 18 year old patient presented with abdominal pain that had started one day previously. Physical examination revealed overall abdominal tenderness with rebound tenderness. Abdominal bloating was noted.

The patient had a temperature of 38.2 ℃ with an elevated C-reactive protein (CRP) level of 16.92 mg/L. Laboratory tests for hormonal abnormalities showed levels that were lower than the normal limits. She had a normal 46,XX chromosome pattern. Abdominal computed tomography and magnetic resonance imaging (MRI) revealed no vagina, and diffuse collection of hemorrhagic fluid was observed in the cervical canal and uterine cavity, which extended up to the umbilical level (Figures 1B & 1C). The lower vagina was not fully developed, and the upper vagina and uterine body were hypoplastic. The right ovary was identified on sonographic examination, but the left ovary was not found. The perineum was obliterated by a membrane (Figure 1D). She had breasts and pubic hair with prepubescent features (Figure 1A); however, she had not had her first menses. She had a medical history of growth hormone treatment for small stature between ages 7 and 14 years. A brain MRI was obtained during that treatment, and no structural abnormalities were noted. Initially, antibiotics were prescribed to control infection; however, her CRP level increased to 18.51 mg/L, and the patient complained of severe abdominal pain (Numeric Rating Scales 8-9). It was concluded that the patient needed immediate surgical intervention for the drainage of the pus in the uterine cavity and to correct the abnormal vaginal structure. The perineal membrane structure was incised in a ‘+’ shape under sonographic guidance. Approximately 1000 mL of foul-smelling yellow fluid was drained (Figure 1E). There was no visible lower vagina, and the upper vagina was pulled downward and sutured to the perineal incision site with 3-0 Polysorb sutures to create a hymenal opening. Subsequently, a drainage duct was inserted for additional drainage of fluid from the uterus (Figures 1F & 2A).

Figure 1:A. Tanner scale III breast budding and tanner scale I pubic hair.

B. Initial coronal computed tomography (CT) scan shows hematometrocolpos with vaginal agenesis and urinary bladder distension due to extrinsic compression by the hematometrocolpos.

C. Initial sagittal CT scan shows that the hematometrocolpos was distended at the level of the umbilicus.

D. Preoperative view of the perineum. The opening of the vagina cannot be seen because it is hidden by the membrane.

E. After incision, yellowish pus was drained.

F. A Penrose drain was inserted postoperatively.

Three days after the procedure, her CRP level had decreased to 5.5 mg/L. The drainage duct was removed, and a vaginal mold was made to prevent future vaginal stenosis. A condom was inserted into the neovagina to create a mold, and it was filled with alginate (alginic acid, one of the impression materials used for shaping teeth before dental procedures such as placement of crowns or implants). We were then able to easily obtain her vaginal length and diameter. Next, using a 3D printer, a customized mold was created. This mold, with a diameter of 1.5 cm and a length of 10.5 cm, was created using an ALMOND 3D printer (OpenCreators, South Korea) (Figures 2B,2D & 2E). The patient was instructed to use the mold with lubricant during normal activities and during sleep. She had difficulty voiding during the first few days, but this improved after 4 days. She was discharged 10 days postoperatively. The patient was followed up every 6 months, and an additional 2cm diameter mold was made for post vaginoplasty management (Figures 2F & 2G). She did not show any vaginal stenosis (Figure 2C) and did not complain of discomfort. We plan to continue management with this mold and follow up with this patient.

Figure 2:Vaginal molds:

A. Immediately after surgery; a Penrose drain, with a diameter of 12 mm, and two straws inside the drain.

B. The 3D printed vaginal mold first used 7 days post-surgery.

C. The neovaginal cavity without constriction approximately 3 months post-surgery.

D. D, E: The initial vaginal mold. (Diameter: 1.5 cm, length: 10.5 cm)

E. F, G: The vaginal mold first used 6 months post-surgery (diameter: 2 cm, length: 10.5 cm).

Discussion

Vaginal agenesis, also known as Mayer Rokitansky Küster Hauser syndrome or Müllerian agenesis, is a rare congenital disorder that can be accompanied by renal agenesis, cardiac anomalies, or skeletal anomalies. The uterus may be partially developed or entirely undeveloped. Vaginal agenesis is treated both surgically and non-surgically. One treatment goal is to enable normal sexual activities. In the United States and the United Kingdom, vaginal dilation is considered to be the most important treatment for vaginal agenesis. In 2013, the American College of Obstetrics and Gynecology recommended that vaginal dilation be the first line of treatment for this condition [4]. This procedure involves the creation of a neovagina with a McIndoe vaginoplasty, which involves lining the vaginal space with a skin graft, followed by the application of a mold to prevent constriction of the newly created vaginal canal. A dilator is generally used daily for 3 months, then only nocturnally for the next 6 months. The success rate of this procedure is around 80% [5]; inflammation of the skin graft, infection, hematoma, and fistula formation are possible causes of failure. The ideal material for the vaginal mold has not yet been established; numerous types of material have been reported without any proven superiority [5]. Soft material is often used for packing immediately after surgery owing to its advantage of enabling bleeding control by applying pressure. The development of a vaginal mold by packing povidone-iodine gauze into a condom has been previously reported [6]. Hard material is recommended to be used beginning 1 week after surgery and continued until regular sexual activity is initiated. Nontoxic polypropylene material is often used to make hard vaginal molds because it is lightweight.

In 2014, Manu Rathee reported successful treatment without complications using a hollow vaginal stent made by coating a wax scaffolding with acrylic [7]. The authors considered that a mold that could be easily manufactured while accurately reflecting the anatomy of the patient would help obtain good results. We thought that 3D printing was most suitable for this purpose, and thus, we selected TPU, which is a flexible, abrasion-resistant, thermoplastic material that allows easy printing and offers good durability. We created the vaginal mold using the ALMOND 3D printer manufactured by OpenCreators Cooperation. This 3D printer uses the fused deposition modeling method, which involves melting a thin thread like thermoplastic and depositing it in a thin film to be printed. The operation of this printer is simpler than that of other 3D printers. In addition, it is easy to manufacture vaginal molds using this approach because of its low price and widespread accessibility. Currently, 3D bioprinting in the medical field is still in its early stages. A customized pessary made with 3D printing technology has been reported for gynecologic use [8,9]. In the present case, we successfully implemented postoperative management using a vaginal mold developed using 3D printing. There are fewer concerns of rejection, degradation, and material biomimicry with TPU, and it can be easily individualized and is safe for semi-permanent use. Further, the mold can be used by the patient hygienically without the inconvenience of putting it in and taking it out.

Our vaginal mold had two advantages. First, we were able to sequentially increase the size of the mold on an outpatient basis, and it was still customized for the patient. Second, the mold was lighter and thus more comfortable compared to the readymade molds. However, there were some disadvantages. Although TPU has better shock absorption and durability compared to other materials, it was damaged during use in our patient’s case. Furthermore, the material was not antibacterial, leading to repeated vaginitis infection during the course of the use of the mold. Future considerations would include using antibacterial materials for the mold. This report is the first to suggest using a 3D printer to create molds to maintain vaginal dilation after the creation of a neovagina. This case report demonstrates how a 3D-printed vaginal mold can aid in the maintenance of the vaginal structure in a patient with a partially developed vagina. Successful neovaginal reconstruction was achieved using a 3D printed vaginal mold, and this approach can be applied for patients with vaginal agenesis and stenosis and can be used as a novel method for maintaining the neovaginal structure without affecting the patient’s quality of life.

 

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Understanding Barriers and Facilitators for Telehealth Implementation in Healthcare Delivery System During COVID-19- Call for Action

Introduction

The five dimensions of access are availability, accessibility, accommodation, affordability, and acceptability [1]. Availability is a relationship between the volume of facilities, healthcare supplies, and patient’s healthcare needs volume [1]. Accessibility defines the distance between patient and provider, meaning travel time and transportation factors to seek healthcare service [1]. Accommodation defines the relationship between the delivery system, the structure of healthcare facilities set up to accept patients, and the patient’s ability to accept it [1]. It includes appointment timings, hours of operations, mobile services, walkin facilities, etc. [1]. Affordability is the relationship between the healthcare provider’s charges for the services they provide and the patient’s income ability to pay for the services they might seek from those providers [1]. Finally, acceptability means both the patient’s and provider’s tendency to accept the attributes of each other [1]. Meaning, patients might be willing to go to certain types of facilities, neighborhood, provider gender, or providers’ race.

Likewise, the providers might not be willing to accept certain patients holding a kind of insurance coverage they don’t accept [1]. It is established that if a problem exists among any dimensions of access, it could influence patients and healthcare delivery systems that are measurable in three ways [1]. First is lowered utilization of services, lower patient satisfaction of the healthcare services they receive, and change in provider practices like reduced patient time [1]. It is evident from the above paragraph that access and utilization are hence interrelated, and access could be measured through utilization [2]. The utilization of healthcare services serves as an indicator to determine whether access to needed healthcare is realized [3]. The frequency of visits to a physician/provider or medical procedure all fall under the utilization indicator of access to healthcare [3]. The structure of a delivery system (accessibility), the process of care (accommodation, acceptability, affordability), and health outcomes seem to affect and assess (Figure 1 in Appendix) overall access to care, costs, and quality [4].

The common barriers to access to healthcare are structural (availability, delivery system organization and transportation), financial (insurance coverage, reimbursement levels, and public support), and personal (acceptability, cultural, language, attitudes, and education/income), which affects health and wellbeing of an individual [3]. Measures of access, i.e., utilization of healthcare services and health outcomes, vary as per the equity measures, i.e., barriers to access [3]. Overall, it is evident through Figure 1 in the appendix and literature [5] that healthcare utilization is an indicator of access to healthcare affected by structure, process, and individual characteristics. Nonfinancial barriers to access are common reasons behind unmet need or delayed care among Adults in the United States compared to affordability barriers [6]. Attempts to improve such access through the Affordable Care Act (ACA) Legislation is the one source to improve it as the absence of insurance means no access to the healthcare delivery system [7].

Figure 1:How U.S. healthcare system can be evaluated [4]. Effectiveness, efficiency and equity indirectly measures components of healthcare i.e. Structure, Process and Outcome as they affect Access, Cost and Quality.

However, the non-financial barriers to access couldn’t be solved by ACA but by federal and state governments through infrastructure development [6] and changing care delivery patterns like Accountable Care Organizations [8]. The solution to the availability domain issue for access could be increasing the supply of providers and healthcare services in the underserved area [6]. Patients seeking primary care at community healthcare centers are more likely to receive preventive services, Pap smear, vaccinations and, less likely to have low birth weight babies, less likely to visit or seek care in emergency rooms [7]. Several mechanisms through which primary care benefits occur are greater access to needed services and early management of health problems [7]. Greater access to required services improves healthcare services access for disadvantaged population groups who are more prone to lack of regular source of care [7].

Early management of health problems by preventing causes and symptoms like hypertension complications occurs through primary care that could help avoid emergency department visits or hospitalizations and disease progression [7]. Healthcare costs also rise with increased utilization of high-cost services or emergency department visits caused due to unmet medical needs and timely access to care barriers [9]. Integrating medical and non-medical services into a healthcare delivery system could help reduce the cost by improving access to needed care [9]. Accessibility, a nonfinancial access barrier to receiving timely healthcare services, could be improved through telemedicine and transportation services [6]. Alternative payment models have also proven to improve the quality and utilization of healthcare [10]. The access and utilization of healthcare seem to strengthen due to primary care facilities and their providers [7]. Accountable Care Organizations also reduce healthcare costs [11,8], emergency department visits [8], and improve overall healthcare utilization [10].

So, the accommodation domain of access could be improved through open access scheduling to reduce wait time for primary care and or reduce avoidable Emergency Department visits [6]. Disparities in healthcare utilization exist among racial and ethnic groups [12,13]. Access to healthcare and insurance coverage constitutes this racial and ethnic disparity [12]. Specific governmental interventions like Medicaid Expansion under ACA legislation have effectively reduced such utilization disparities in the United States [12,14,15]. Differences could also be potentially eliminated by managed care programs performing in certain states with vulnerable beneficiaries if enrolled [13]. Increased utilization of acute healthcare services by the homeless population also exists as a disparity compared to other groups [16]. Certain vulnerable groups might also face barriers to access to healthcare due to unmet non-medical needs at an early stage and hence causes an increase in overall healthcare expenditure [16]. Patients and providers also play a vital role in help identifying the barriers to access to care, quality of care, or general issues they face regarding the process of healthcare they receive [17,18] It could help reduce the disparity associated with utilization among the vulnerable group of patients with unmet medical needs.

Problem Analysis- Issues with Influencing Telehealth and Healthcare Utilization

Before the COVID-19 pandemic, disparities in healthcare utilization were evident, while during the pandemic, disparities within the individual healthcare system for telehealth service utilization exists depending on the patient’s socio-economic status [19-24]. Several significant barriers from the patient side are disparities in digital access, digital literacy, telehealth awareness, cost & coverage for telehealth, racial and ethnic discrimination, low income and, rural population [22,23]. The structural-level barriers influencing telehealth services are broadband services availability and quality, licensing regulations for providers, and equitable telehealth insurance service reimbursements [20,21,25]. The provider-level barriers are insufficient resources to support virtual care [21,22], inability to obtain physical examination vitals, and lab work [26].

In the absence of policies and interventions to improve access to care through telehealth service utilization, these disparities may broaden [19]. Although Telemedicine utilization has improved among population groups with higher income, it has disproportionately reduced among lower-income, education groups of population with specific cultural and political factors playing the role as mediators for the disparity [19]. Currently, a significant barrier to population-level implementation of telehealth during COVID-19 is workforce challenge with a single remote clinician for multiple sites, credentialing, payments/reimbursements, staffing of specialists, and infrastructure in place to implement telehealth effectively [27]. The pandemic has affected Emergency Department visits which might impact the overall health outcome of the population requiring the visit [28]. It is vital to understand the root causes of the decreased Emergency Department visits in pandemic and its impact on overall population health outcomes [28]. It is also essential to determine what impacts provisions of services like telehealth that provide continuity of care. Its implementation leads to improving the cost and quality of healthcare for all types of patients.

Application of Andersen and Aday Model- Empirical Literature

The U.S. healthcare service continuum could be divided into primary, secondary, and tertiary [4], as depicted in (Figure 2 Appendix). So, it is vital to evaluate and determine the application of any model across the continuum of care to understand the effects on access and utilization of healthcare. The Andersen and Aday Model helps us understand and evaluate the structure process and the outcome along and across the continuum [4]. The conceptual framework proposed by Andersen and Aday inculcates system, institution, and patient/individual level constructs that help determine the relationship and define a problem in health services research [5]. It helps provide descriptive data on the organization (structure) and operation (process) of the healthcare system. It also helps to understand the percent people uninsured, the proportion and distribution of providers, and overall healthcare service utilization [4]. The model helps understand, examine, and evaluate the relationship and impact of one component on the other (Figure 3 Appendix) as depicted by the directions of arrows in the model [5].

Figure 2:U.S. healthcare service continuum [5].

Figure 3:The framework of the model helps evaluate health care service, program, and policy through interrelation of model constructs [5].

Overall, it helps analyze (Figure 4 Appendix) the impact of the healthcare delivery system, other patient characteristics on the overall health and wellbeing of the population it was developed to serve [4]. It helps understand the impact and analyze the impact of the healthcare delivery system and personal characteristics/ demographic characteristics at both population-level, i.e., population perspective, and clinical level, i.e., clinical perspective including system, individual or organizational level [4]. The model can be studied at both the macro and micro levels to determine the outcome [4]. Overall health and wellbeing could be measured by measuring health indicators. Finally, effectiveness, efficiency, and equity criteria help understand and evaluate if the existing policy, intervention, or practice are efficient, equitable, and effective [4]. Effectiveness, efficiency, and equity are often complementary [4].

Figure 4:Andersen and Aday final phase model [5].

Effectiveness in clinical perspective is medical treatment effectiveness, while a population perspective its medical and non-medical (environmental and behavioral) effectiveness of intervention [4]. On the other hand, efficiency means cost-benefit analysis or cost-effectiveness, or cost-utility analysis [4]. It means if indeed within the limited resources, the available treatment is effective and low at the cost compared to other alternatives [4]. Finally, Equity Helps determine if the effective and efficient intervention is available equally or distributed equally to all? [4], Is there procedural fairness at the structural and process level to make this effective and efficient intervention available to all groups? The Model helps determine the performance of the U.S. healthcare system and policy impact on the healthcare system, as we refer to Figure 3 in Appendix [4]. The application of the structure process and outcome model to determine healthcare quality [29], variation in resources, and impact of delivery system on patient outcomes and utilization [30] determined in the past. The Healthcare system is complex [31].

In such cases, evaluation of either change in infrastructures like telehealth or the characteristics of both patient/provider and systems providing care [32] through the application of Andersen and Aday model is evident in the past. The delivery system or any intervention proposed needs be measured through the lens of effectiveness and efficiency [33]. The model utilizes measures and attributes of the healthcare delivery system like structure, process, and outcome to determine and evaluate the health and well-being of the population it serves. With the model, both the provider and subgroup of problems, including demographic characteristics (predisposing, need, and enabling factors) and its intervention, are evaluated [33]. Including the demographic characteristics in the model helps us understand how target population characteristics needs are addressed by existing system performance or network and how their overall health and well-being are being impacted? [33].

Hence it is crucial to determine while implementing this model, who is the target population of interest? Is it homeless people, children, or doctors protected against COVID-19 infection through the implementation of telehealth, or is its population protected from COVID-19 infection? It is also important to note that effect and outcome at all levels (population and clinical) are essential to analyze as new technology and service might be effective and work at an individual level but might not work at a population level (scale-up problem) as discussed in the book [4]. To fully understand the effect of health programs, interventions, or policy, the impact at each level (Figure 5 in Appendix) is necessary to be determined [4].

Figure 5:Indicators and measures illustrate potential predictors and outcomes for the health service utilization and delivery system outcomes [5].

Application of Andersen and Aday Model Within Context of Telehealth Utilization

Studies examining disparity in healthcare access and utilization so far have utilized the model to construct the research variables for outcome measures of healthcare utilization [12]. The indicators of healthcare access and utilization measured are “probability of being uninsured, probability of having any delayed necessary medical care, and probability of having any forgone medical care” [12]. Hence the model can determine the impact of telehealth services on healthcare utilization both at the population and clinical perspective level. Health care utilization measures are the probability of having an emergency department (E.D.) visit, and probability of having any physician visit” [12]. The covariates of the study can be informed by the model [12] categorized into three domains like predisposing factors, enabling factors, need factors. Hence, the model provides information on mechanism through which outcomes like healthcare utilization are impacted other than telehealth intervention as a primary treatment variable.

Studies have applied the model to understand process level barriers of utilization and their impact on the overall quality of health, i.e., under or overuse of healthcare services of a particular specialty [34,35]. One study utilizes only process and outcome level data to determine the adequacy/effectiveness of existing healthcare delivery and services [34]. So, telehealth service’s effectiveness on the current healthcare delivery system can be measured by applying Andersen and Aday Model in determining impacts on health care service utilization among primary care and preventive care population during COVID-19 [24]. The Anderson and Aday model could be utilized in stages to determine the effectiveness of telehealth utilization [33]. In the first stage, we could use the model to determine the system-level factors impacting telehealth utilization, affecting the overall continuity in healthcare utilization for chronically ill and other preventive services [36]. By doing so, we would measure the system performance and gather existing evidence [33,25].

In the second stage, one can implement the model to determine and establish standard guidelines of the process of care [33] for telemedicine and its utilization. Once the standard guidelines are determined, the indicators for measurements from the guidelines could be established for each construct of the model to establish the quality of telemedicine care or delivery system [33]. In the final stage, the quality outcomes could be utilized to develop strategies for improvement and reanalyze the outcomes after implementing those strategies [33] identified regarding telehealth implementation and utilization. The model could also evaluate a socioeconomically vulnerable group of population [37,24] facing disparity in telehealth utilization within the healthcare system [19]. The model evaluates several factors that make the population vulnerable and uses them to determine its impact on their healthcare utilization [37], as factors that make the group vulnerable might be responsible for the effect on the overall utilization of care [37]. The model application for the vulnerable population could help determine the effect of telehealth healthcare utilization on the health outcomes/status of the group as health status determines utilization [37].

It is vital to understand whether COVID-19 has brought changes in disparities associated with telehealth utilization within any healthcare system [19,24]. The U.S. Centers for Disease Control and Prevention recommends utilizing Telehealth services during the pandemic to seek needed care. Hence Andersen and Aday model could help determine the uptake rate of telehealth services through the number of visits via telemedicine and its impact on timely access to care and health care utilization [24]. The model can also help identify potential structure, process, and individual level barriers [38,39,23] that could impact telehealth utilization among the vulnerable population [22] and how it impacts the overall access to primary care [22]. As established prior (Figure 1, Appendix) in this paper, structure and process-level factors impact and can be assessed by the access to health, healthcare utilization, and quality of care components.

It is vital to understand how the pandemic affects the complexity gap between the needs and services of patients for chronic care [32]. The reason behind doing so is to understand the impact on service utilization and overall health and well-being among the population with chronic conditions other non-acute, non-urgent care needs. Hence the model can help determine barriers and facilitators of Telehealth and Remote Patient Monitoring Programs [40,41] to determine effectiveness [22], efficiency, and equity aspects of such [38,39] during COVID-19 pandemic. Overall, the Andersen and Aday model can be utilized to measure the impact of telehealth on healthcare utilization (over/underutilization of needed services), readmission rates for specific condition groups, improved quality of care through telehealth [21,22,28], and impact of telehealth on reducing overall cost of care through improved access to care [20,21].

Conclusion

Structure, process, and outcome constructs in health services research seem to affect healthcare access, cost, and quality. Hence it is vital to utilize the model to determine what aspects of structure (delivery system, population characteristics) and process (utilization, satisfaction) affect utilization, access outcomes like physicians visit, utilization of proposed interventional services, or use of emergency department visits. Quality of care could help determine if the existing care provision is appropriate or not and could serve as an indicator of access and utilization. Since the constructs of the framework are interrelated, like vulnerable population’s need for care and existing system delivery together impact the process of care and the health risks the population carry which in turn impacts the overall health of the population, its crucial to utilize the entire model to understand the complex situations that affect telehealth and utilization of care. It is also established that utilization of healthcare and health outcomes serve as an indicator of access to needed healthcare in this paper. Barriers to access to telehealth services impact the overall health outcomes and over or underutilization of needed healthcare. Application of the Andersen and Aday Model to telehealth service utilization and its impact on overall healthcare utilization in health services research can help inform government policies relevant to its effectiveness, equity, and efficiency. The model can also help understand facilitators, barriers for telehealth implementation in the healthcare delivery system. It also helps understand the disparity in health outcomes among the population and specific groups and the quality of healthcare service.

 

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