Multi-level zero-inflated Poisson regression modelling of correlated count data with excess zeros

Count data with excess zeros relative to a Poisson distribution are common in many biomedical applications. A popular approach to the analysis of such data is to use a zero-inflated Poisson (ZIP) regression model. Often, because of the hierarchical Study design or the data collection procedure, zero-inflation and lack of independence may occur simultaneously, which tender the standard ZIP model inadequate. To account for the preponderance of zero counts and the inherent correlation of observations, a class of multi-level ZIP regression model with random effects is presented. Model fitting is facilitated using an expectation-maximization algorithm, whereas variance components are estimated via residual maximum likelihood estimating equations. A score test for zero-inflation is also presented. The multi-level ZIP model is then generalized to cope with a more complex correlation structure. Application to the analysis of correlated count data from a longitudinal infant feeding study illustrates the usefulness of the approach.

Videophone support for an eight-year-old boy undergoing paediatric bone marrow transplantation

We report the use of an Internet-based videophone to support a child undergoing bone marrow transplantation (BMT). Over the Christmas period, an eight-year-old boy with an underlying diagnosis of attention-deficit/hyperactivity disorder (ADHD) and a history of absconding and aggressive non-compliant behaviour was treated by BMT. We installed an Internet-based videophone in the patient's hospital room two days post-transplant. A second videophone was installed in the patient's home and used the existing home telephone line. In all, 14 videophone calls were made over a nine-day period. The videophone improved interfamily social and emotional support, and appeared to reduce some of the inherent anxiety and distress resulting from paediatric bone marrow transplantation.

Realtime telemedicine

Telemedicine conducted via prerecorded interaction is more convenient than that using realtime interaction. On the other hand, a realtime consultation allows an immediate result to be obtained and there is likely to be a strong educational component for the remote practitioner. The use of the telephone is under-rated in telemedicine. Telephones have been used in outpatient follow-up, mental health, help lines and support groups. Telephones (fixed and mobile) have also been used for data transfer (e.g. for transmission of electrocardiograms). Realtime transfer of still images has been used in telepathology for many years, and more recently for rapid assessment of injuries. Realtime transfer of video images has been widely explored, perhaps most successfully in telepsychiatry. Some realtime telemedicine applications have been taken up with enthusiasm, even if formal evidence of cost-effectiveness may be lacking. Teleradiology and telepsychiatry are two examples where widespread adoption is beginning to occur. Other forms of realtime telemedicine represent 'niche' applications. That is, they appear to be both successful and sustainable in the centres where they were pioneered, but have not been adopted elsewhere. Teledialysis and teleoncology are examples of this type. The patchy diffusion of telemedicine is something that is not yet well understood.

Knowledge, perceptions and expectations of nurses in e-health: results of a survey in a children's hospital

We surveyed all nurses working at a tertiary paediatric hospital (except casual staff and those who were on leave) from 27 hospital departments. A total of 365 questionnaires were distributed. There were 40 questions in six sections: demographic details, knowledge of e-health, relevance of e-health to nursing profession, computing skills, Internet use and access to e-health education. A total of 253 surveys were completed (69%). Most respondents reported that that they had never had e-health education of any sort (87%) and their e-health knowledge and skills were low (71%). However, 11% of nurses reported some exposure to e-health through their work. Over half (56%) of respondents indicated that e-health was important, very important or critical for health professions while 26% were not sure. The lack of education and training was considered by most respondents (71%) to be the main barrier to adopting e-health. While nurses seemed to have moderate awareness of the potential benefits of e-health, their practical skills and knowledge of the topic were very limited.

A systematic review of successes and failures in home telehealth: preliminary results

We conducted a systematic review of the literature to identify studies in home telehealth that compared a home telehealth intervention with a non-telehealth standard/usual care alternative in terms of administrative changes, patient management decisions, patient outcomes, caregiver outcomes, economic impact or social impact on patients. A search of various databases produced 6643 references. Of these 769 papers were selected for more detailed investigation. These papers, combined with hand searching of relevant telehealth journals and cross-referencing of citations in identified publications, resulted in 138 papers referring to 130 projects for review. In this preliminary analysis we used a quality appraisal approach that took into account the study design. An additional analysis of patient numbers was then used to calculate a net evidence score. A large proportion of studies (80%) were randomised controlled trials. Only 22 projects (17%) reported economic data deemed to be sufficient for appraisal. Evidence exists for the clinical effectiveness of home telehealth in diabetes, the general area of mental health, high risk pregnancy monitoring, heart failure and cardiac disease.

A bibliographic snapshot of the telemedicine citation literature

There appear to have been no previous literature-based or literature-oriented studies in telemedicine which have analysed raw citation data. Using a simple search strategy, the Web of Science was analysed up to the end of 2005 to give a snapshot of the field, and to identify matters which would need to be considered in larger scale bibliometric studies. Of the 3673 telemedicine documents retrieved, 2213 (60%) had been cited. Of 56,875 citation records, 32,460 unique citation formats were found. The most-cited paper, and the paper with the greatest annual citation rate, was Perednia and Allen's review article in JAMA, 1995. The two specialist telemedicine journals published 40% of all papers retrieved. In the general literature (i.e. excluding the two specialist journals) there were 1556 citations to their 1374 'citable' articles, apportioned in the ratio 76:24, almost exactly in accordance with the distribution of the articles themselves. However, each of the two specialist telemedicine journals cited itself in a proportion higher than its share of original articles, with an 'excess' of self-citations of 14% in the journal of Telemedicine and Telecare, and 19% in the Telemedicine journal and E-Health. Despite certain technical difficulties, there is considerable scope for bibliometric research in telemedicine.

Treating the speech disorder in Parkinson's Disease Online

The Lee Silverman Voice Treatment (LSVT) has been shown to be highly effective in treating the speech disorder in Parkinson's Disease (PD). However, patient access to this treatment remains limited in Australia, due to availability of speech pathologists, patient mobility and distance issues. We have investigated the feasibility and effectiveness of an Internet-based telerehabilitation application (eREHAB) for the delivery of the LSVT to persons with PD and disordered speech. Ten participants with PD and dysarthria were treated online with the LSVT for a total of 16 sessions. There were significant improvements in sound pressure levels for vowel prolongation, reading and conversational monologue (P < 0.01), pitch range (P < 0.05) and in perceptual features of pitch and loudness variability, loudness level (P < 0.01) and breathiness (P < 0.05). A participant satisfaction questionnaire indicated that 70% of participants expressed overall satisfaction with the online treatment. Telerehabilitation was feasible and effective in delivering the LSVT to people with PD.

A pilot study of online assessment of childhood speech disorders

We investigated the feasibility of assessing childhood speech disorders via an Internet-based telehealth system (eREHAB). The equipment provided videoconferencing through a 128 kbit/s Internet link, and enabled the transfer of pre-recorded video and audio data from the participant to the online clinician. Six children (mean age = 5.3 years) with a speech disorder were studied. Assessments of single-word articulation, intelligibility in conversation, and oro-motor structure and function were conducted for each participant, with simultaneous scoring by a face to face and an online clinician. There were high levels of agreement between the two scoring environments for single-word articulation (92%), speech intelligibility (100%) and oro-motor tasks (91%). High levels of inter- and intra-rater agreement were achieved for the online ratings for most measures. The results suggest that an Internet-based assessment protocol has potential for assessing paediatric speech disorders.

Symptom prevalence and clustering of symptoms in people living with chronic hepatitis C infection

Quality of life has been shown to be poor among people living with chronic hepatitis C However, it is not clear how this relates to the presence of symptoms and their severity. The aim of this study was to describe the typology of a broad array of symptoms that were attributed to hepatitis C virus (HCV) infection. Phase I used qualitative methods to identify symptoms. In Phase 2, 188 treatment-naive people living with HCV participated in a quantitative survey. The most prevalent symptom was physical tiredness (86%) followed by irritability (75%), depression (70%), mental tiredness (70%), and abdominal pain (68%). Temporal clustering of symptoms was reported in 62% of participants. Principal components analysis identified four symptom clusters: neuropsychiatric (mental tiredness, poor concentration, forgetfulness, depression, irritability, physical tiredness, and sleep problems); gastrointestinal (day sweats, nausea, food intolerance, night sweats, abdominal pain, poor appetite, and diarrhea); algesic (joint pain, muscle pain, and general body pain); and dysesthetic (noise sensitivity, light sensitivity, skin. problems, and headaches). These data demonstrate that symptoms are prevalent in treatment-naive people with HCV and support the hypothesis that symptom clustering occurs.

Government relations, government regulations: jumping through the hoops

Over the last decade, telehealth in Australia has been primarily facilitated and driven by government funding. The government now has a major policy initiative in online health. However, in pursuing the broad initiative there is a danger that some of the smaller components can get lost, and this is probably what has happened to telehealth. There appear to be a number of steps required if telehealth in Australia is to keep up the pace of development that occurred in the 1990s, as we move into what is now being called the era of e-health, involving broadband Internet health service delivery. This area is changing extremely rapidly and is increasingly migrating away from the public sector in Australia, where most of the developmental work has occurred, and into the private sector. Many of the issues that require consideration within the domain of e-health in Australia are also relevant to other countries. E-health will significantly change the way that health-care is practised in future, and it is clear that it is the human factors that are more difficult to overcome, rather than the technological ones.

Problem-based learning: a case study in providing e-health education using the Internet

The current trend among many universities is to increase the number of courses available online. However, there are fundamental problems in transferring traditional education courses to virtual formats. Delivering current curricula in an online format does not assist in overcoming the negative effects on student motivation which are inherent in providing information passively. Using problem-based learning (PBL) online is a method by which computers can become a tool to encourage active learning among students. The delivery of curricula via goal-based scenarios allows students to learn at different rates and can successfully shift online learning from memorization to discovery. This paper reports on a Web-based e-health course that has been delivered via PBL for the past 12 months. Thirty distance-learning students undertook postgraduate courses in e-health delivered via the Internet (asynchronous communication). Data collected via online student surveys indicated that the PBL format was both flexible and interesting. PBL has the potential to increase the quality of the educational experience of students in online environments.

Developing a protocol for the use of telenursing in community health in Australia

As the first step in developing a protocol for the use of video-phones in community health, we carried out a feasibility study among clients with a range of health needs. Clients were equipped with a commercially available video-phone connected using the client's home telephone line. A hands-free speaker-phone and a miniature video-camera (for close-up views) were connected to the video-phone. Ten clients participated: five required wound care, two palliative care, two long-term therapy monitoring and one was a rural client. All but two were aged 75 years or more. Each client had a video-phone for an average of two to three weeks. During the six months of the study, 43 client calls were made, of which 36 (84%) were converted to video-calls. The speaker-phone was used on 24 occasions (56%) and the close-up camera on 23 occasions (53%). Both clients and nurses rated the equipment as satisfactory or better in questionnaires. None of the nurses felt that the equipment was difficult to use, including unpacking it and setting it up; only one client found it difficult. Taking into account the clients' responses, including their free-text comments, a judgement was made as to whether the video-phone had been useful to their nursing care. In seven cases it was felt to be unhelpful and in three cases it was judged helpful. Although the study sample was small, the results suggest that home telenursing is likely to be useful for rural clients in Australia, unsurprisingly, because of the distances involved.

A comparison of telepaediatric activity at two regional hospitals in Queensland

We conducted a 15-month feasibility study of telepaediatrics. A novel service was offered to two hospitals in Queensland (Mackay and Hervey Bay). We used data from all other hospitals throughout the state as the control group. Although both intervention hospitals were provided with the same service, the telepaediatric activity generated and the effect on admissions and outpatient activity were markedly different. There was a significant decrease in the number of patient admissions to Brisbane from the Mackay region. In addition, there was an increase in the number of Mackay patients treated locally (as outpatients). In contrast, little change was observed in Hervey Bay. We assessed whether the observed differences between the two hospitals were due to various factors which influenced the use of the telepaediatric service. These factors included the method of screening patients before transfer to the tertiary centre and the physical distance between each facility and the tertiary centre. We believe that the screening method used for patient referrals was the most important determinant of the use of the telepaediatric service.