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Building Improved and Sustainable Health-Care Systems Through Telemedicine


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Telemedicine—the remote diagnosis and treatment of patients via telecommunications technology—has changed the way oncology care is delivered in rural parts of the world. Patients in rural areas are now able to connect remotely with their physicians without having to deal with the time, expense, and lost productivity associated with traveling to a cancer center. Perhaps more importantly, patients who might otherwise have gone without treatment are now receiving the care they need. At the 2018 World Cancer Congress in Kuala Lumpur, Malaysia, researchers from around the globe shared their experiences with using telemedicine to build sustainable health-care systems in their communities.

Bridging the Gap Between Urban and Rural Oncology Care in Kenya

Like the rest of Africa, Kenya’s population is predominantly rural, and providing quality oncology care in rural areas remains fraught with unique challenges. In Kenya, there is an extremely low physician-to-patient ratio—approximately 1:17,000. Fully supporting a rural clinic comes at a high cost, and the price of traveling to a health-care clinic translates to wage losses and a familial burden for patients.

“These travel times and high costs limit patient follow-up, creating a poor environment for successful treatment,” said Samuel Mbunya, Program Administrator at AMPATH Oncology Institute, who spoke about strategies for lessening the disparities between rural and urban oncologic health care.1

According to Mr. Mbunya, telemedicine is a viable and necessary resource for developing oncologic care in rural Kenya and other low- and middle-income countries. It provides a lower-cost, practical method for maximizing physician resources, while limiting cost and stress to families with socioeconomic limitations and allowing for a larger audience reach without lengthy commutes.


Telemedicine should assist patients to overcome the barriers of cost and time that limit their treatment. That’s as simple as it gets.
— Samuel Mbunya

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The AMPATH (Academic Model for Providing Access to Healthcare) Consortium has served to greatly expand health care—and particularly oncology care—in Western Kenya. A collaboration among Moi University, Moir Teaching and Referral Hospital, North American medical schools led by Indiana University, and the Kenyan Government, AMPATH has worked to build sustainable cancer care systems in Kenya and other low-income areas of the world, largely through the use of telemedicine.

AMPATH employs 12 oncology specialists who travel to rural clinics to provide chemotherapy and other treatments, but the average travel time to these clinics is over 3 hours. The Consortium does receive funding from pharmaceutical companies to cover these costs, but the way the money is currently spent is not sustainable: over $2.7 million is spent solely on physician travel for all 17 AMPATH clinics yearly. Alternatively, patients can travel to the Eldoret central clinic for about $15, but considering an average wage of only $2 per day, this is hardly a more sustainable option. Compounding the problem is the fact that patients rarely make the trip alone, and adding two or three family members to the journey significantly increases the cost.

Enter Telemedicine

The cost of setting up a telemedicine center in an AMPATH center is approximately $4,380. According to Mr. Mbunya, the telemedicine model saves $528,560 per year—solely on travel costs—for all 17 AMPATH clinics. “Telemedicine should assist patients to overcome the barriers of cost and time that limit their treatment,” he said. “That’s as simple as it gets. Saving over $500,000 is tremendous and can create many more telemedicine centers.”

AMPATH focuses on two key areas in regard to telemedicine: consultations (physician-physician or physician-patient) and tumor boards. “We hold tumor boards every Monday, and we discuss interesting or difficult cases via teleconference,” he added. “We’re able to discuss cancer cases and provide ways forward. It’s very helpful.”

The group also trains their health-care providers using the telemedicine model. This allows fully trained oncology professionals to connect remotely with rural clinics and care for patients who might not otherwise have had access to care. The model also allows for international oncology specialists to virtually conduct lectures, consultations, and patient case reviews.

“This is important. We need this,” said Mr. Mbunya. “When it comes to Africa, there is a big disconnect. It’s very important for us to have this model so we’re able to speak as one voice and so that we have a way forward for patients with cancer.”

Gaining support and reimbursement from telemedicine visits will be crucial to ensuring the success of telemedicine in Kenya, he noted.

Using Social Media for Remote Monitoring of Patients in India

The cancer burden in low- and middle-income countries is expected to reach 20 million new cases annually by 2025.2 This global epidemic will lead to substantial challenges for health-care providers in low-resource settings: regions of the world that are already facing a shortage of health-care services. But according to researchers in India, remote monitoring through social media outlets may be a partial solution to these challenges, allowing for more integrated treatment and care pathways across geographic boundaries.3

“By 2025, half of the world’s population growth is going to be concentrated in 9 countries,” said Sanjay Yadav, MBBS, MS, Senior Resident in the Department of Endocrine Surgery at Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India. “So, we need to gear our health-care services to provide this growing population with essential health care.”

A significant challenge lies in the postoperative long-term follow-up required for patients with cancer. Patients in low- and middle-income countries have historically low rates of follow-up, but even within these populations, many people carry smartphones and have access to social media, a technology with usership that has grown exponentially in the past decade. Social media–based remote monitoring can be done at leisure and does not require a costly hospital infrastructure.


Low- and middle-income countries need an eHealth revolution using [social media–based telemedicine] technology in order to achieve the goal of health for all, as the availability of health-care facilities is a problem in these geographic locations.
— Sanjay Yadav, MBBS, MS

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Dr. Yadav and his colleagues conducted a longitudinal study to assess the effect of remote monitoring using social media on compliance, satisfaction, and economic benefit. Patients in the study chose one of two groups: outpatient clinic follow-up (n = 24) or online remote consultation (n = 40). Patient characteristics were evenly balanced between the groups, but patients in the outpatient follow-up cohort lived closer to the study clinic: a mean of 600 km compared to 930 km in the online group.

A total of 248 telesessions were held, with an average of 3.7 teleconsultations per patient. The reasons for tele–follow-up included confirmation of histology reports, medication dosage adjustments, wound evaluation, reporting of calcium levels, and seeking a medical fitness certificate.

Notably, online wound evaluation was on a par with outpatient follow-up, as no patient had to report to the hospital for wound infection. The online intervention saved patients an average of 930 km of travel, and in addition to time and lost wages saved, patients spent less money (a round-trip ticket for second-class travel at this distance on an Indian railway is about $7.50). Compliance was good, and the majority of patients in the social media group were satisfied with their treatment.

Based on these findings, the investigators concluded that remote monitoring ensures satisfactory follow-up and is more cost-effective than hospital-based follow-up for both health-care providers and patients.

Low- and middle-income countries need an eHealth revolution using this type of technology in order to achieve the goal of health for all, as the availability of health-care facilities is a problem in these geographic locations,” they reported. 

DISCLOSURE: Mr. Mbunya and Dr. Yadav reported no conflicts of interest.

REFERENCES

1. Mbunya S: Telemedicine: Bridging the gap between rural and urban oncologic healthcare in Kenya. 2018 World Cancer Congress. Presented October 3, 2018.

2. World Health Organization: Global health observatory data repository, 2011. Available at www.who.int/gho/en. Accessed November 12, 2018.

3. Yadav S: Longitudinal trial of a smart-phone application for tele-follow-up of thyroid cancer patients in context of a developing country: Compliance, satisfaction and cost-benefit analysis. 2018 World Cancer Congress. Presented October 3, 2018.


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