Original Title: État des connaissances - Soins virtuels en pédiatrie

Authors' objectives: The aging of the population and the increasing prevalence of chronic diseases will undoubtedly lead to a significant increase in the demand for continuous home and institutional care, this in the current context of limited professional resources in Québec. Furthermore, the COVID-19 pandemic has led to a major advance in the use of virtual care tools to ensure access to care and services and to promote continuity of care. In addition to information technologies, that are now frequently used, the integration of virtual care modalities into care pathways is of growing interest for the evaluation, treatment and follow-up of patients in specialty medicine. These modalities have the potential to improve access to health care for most patients, but also to foster their engagement in the management of their illness. In the context of a national project on virtual care, the Ministère de la Santé et des Services sociaux (MSSS) has mandated the Institut national d'excellence en santé et en services sociaux (INESSS) to provide a state-of-knowledge report to guide the use of virtual care in specialty medicine. This work will help support or optimize care pathways and support clinical practices and the provision of care and services to patients. The objective of this work is to inform public decision-makers, medical associations, and health and social services professionals about virtual care practices in specialty medicine. The project involves the following seven parts: 1) Pediatrics (this report), 2) Psychiatry, 3) Neurology, 4) Hematology/Oncology, 5) Respirology, 6) General Surgery and 7) Internal Medicine.

Authors' results and conclusions: RESULTS (#1 FINDINGS CONCERNING VIRTUAL CARE IN PEDIATRICS): Most of the virtual care interventions mentioned in the different clinical pathways involve several modalities, such as teleconsultation, telemonitoring, teleeducation, teleassistance and teleintervention. • Teleconsultation and tele-education are the modalities most frequently reported in the reviewed literature. • Many authors of the selected studies conclude that further studies of good quality will be necessary. (#2.1 VIRTUAL CARE PATHWAYS REPORTED AS BEING CLINICALLY EFFECTIVE): Assessment or diagnosis, mainly by teleconsultation, for children with the following clinical conditions: – Neurodevelopmental disorders, in particular, language disorders, autism spectrum disorders, attention deficit disorders with/without hyperactivity and learning disabilities; – Certain cancers; – Certain dermatological conditions, in particular, the inflammatory dermatoses, birthmarks, rashes and acne; – Acute conditions during emergency or intensive care. (#2.2 VIRTUAL CARE PATHWAYS REPORTED AS HAVING POTENTIAL CLINICAL EFFICACY, WHICH IS TO BE CONFIRMED BY FUTURE EVIDENCE: ): Evaluation or diagnosis, mainly via teleconsultation and telemonitoring, of suicidal behaviours in adolescents, particularly in a school setting, urological conditions and certain dermatological conditions; • Monitoring, mainly via teleconsultation, telemonitoring and tele-education, of pediatric patients (adolescents) exhibiting suicidal behaviours, particularly in a school setting, chronic illnesses (e.g., diabetes and anxiety or depressive symptoms associated with chronic pain), infectious diseases, or for ongoing postoperative care after a complex surgical procedure, or for children who have received an organ transplant; (#2.3 FEW RESULTS CONCERNING ORGANIZATIONAL EFFICACY, BUT CERTAIN BENEFITS REPORTED): Improved postoperative care appointment attendance, mainly through the use of tele-education; • Reduced waiting times for children with dermatological conditions through the use of teledermatology, mainly via teleconsultation; • Improved communication between health professionals and families of children in palliative care, mainly through the use of teleconsultation. (#2.4 POTENTIAL BENEFITS OF VIRTUAL CARE REPORTED AS HAVING A POSITIVE IMPACT ON EQUITY OF ACCESS FOR): Children with chronic illnesses, such as asthma, chronic pain and obesity, and those with dermatological or urological conditions, mainly via teleconsultation; • Children with complex needs in underprivileged areas or with particular cultural backgrounds (e.g., mental health problems or chronic illnesses); • Children in remote or rural areas; • Children in palliative care, mainly via teleconsultation; • Children in a school setting (e.g., language disorders or chronic illnesses), mainly via teleconsultation. (#2.5 A PROMISING LEVEL OF SATISFACTION): For patients and care providers, overall satisfaction reported across the different care trajectories is positive, both for assessing or diagnosing various conditions and for monitoring or treating them, e.g., cognitive impairment, mental illnesses, suicidal behaviours, neurodevelopmental disorders, chronic diseases, active cancers, organ transplants, dermatological and urological conditions, and palliative, postoperative, emergency and intensive care. (#2.6 PROMISING RESULTS CONCERNING THE SECURITY AND SAFETY OF VIRTUAL CARE): Virtual care is as safe and secure as in-person care; • Untoward effects and negative experiences are quite rare; • Very low treatment drop-out rates, no worsening of symptoms or medical condition, no complications, and fewer patients who do not continue their followup or who refuse treatment with virtual care. (#2.7 CERTAIN OTHER CLINICAL ACTIVITIES COULD BENEFIT FROM VIRTUAL CARE): Data from guidelines and guidance documents point to clinical activities that could be supported by virtual care, such as: – The assessment of sexual health and of congenital heart disease, genetic abnormalities or retinopathy in preterm infants; – The analysis of laboratory, imaging or specialist reports; Liaison between community and rural nurseries and neonatal and perinatal care specialists; – Assistance to emergency departments in assessing serious illnesses; – Telepsychiatry for adolescents; – Pediatric telecardiology; – Drug therapy dispensing, in particular, in schools, mental health facilities, daycare centres, outpatient clinics and justice facilities; – Pediatric surgery, including pre- and postoperative visits and teleassistance during surgery; – Community-based intensive care. – The management of various chronic gastroenterological diseases; – Pediatric neurological management, e.g., telemedicine outpatient visits, community hospitals and home care. (#2.8 PRACTICES THAT COULD POTENTIATE THE EFFICACY OF VIRTUAL CARE): Evidence from practice guidelines and systematic reviews suggests that the efficacy of virtual care interventions in the pediatric population could be potentiated by: – Assistance for parents in virtual care interventions, especially for children with mental health problems, autism or obesity; – Assistance or guidance from health professionals or therapists to support children during virtual care interventions for monitoring or therapeutic support purposes; – Nurse assistance to support the remote examination when assessing children with mental health problems and/or a chronic illness; – Combining virtual care with in-person care; – Combining several virtual care modalities LIMITATIONS OF SCOPING REVIEW: This report is limited by the following methodological constraints: the type of documents selected, the literature review period of 5 years, the independent study selection for only 10% of the studies, the absence of a formal assessment of the quality of evidence, and the descriptive data synthesis with no meta-analysis. Most of the selected systematic reviews aggregate or select, without distinction, data from primary studies conducted in various care settings with different comparators, clinical situations, and technologies. For meta-analyses, the heterogeneity of the studies and interventions, the small number of studies compared and/or the small number of participants, and the poor quality of the studies are often listed in the limitations. In addition, cultural sensitivity or cultural adaptation and collaborative care, which are topics that should not be overlooked for equity in virtual care, were very rarely addressed. Lastly, limitations pertaining to the study populations and the various measures in the studies also need to be taken into consideration. The field of pediatrics is a clinical specialty encompassing many subspecialties. The literature search therefore yielded very heterogeneous results. Consequently, certain specific care pathways, which could benefit from virtual care modalities, may not have been reported in the reviewed literature. CONCLUSION: Regarding the use of virtual care in pediatrics, the most studied care pathways in the literature on the use of virtual care concern various chronic illnesses. Teleconsultation is the most frequently used virtual care modality in the care pathways studied. However, the reviewed literature reports the simultaneous use of several virtual care modalities. In any event, the modalities are used alone or in combination with other modalities, and virtual care can be used in place of or in addition to standard care.

Authors' methods: A scoping review was conducted to portray the care pathways that might be supported or optimized with the use of virtual care. A review of the scientific and grey literature was carried out for the past 5 years. The existing national and international guidelines, guidance documents and discussion papers, and health technology assessment (HTA) reports published on the topic were also consulted to identify additional pathways or to confirm those identified in the systematic reviews. Documents were selected according to predefined inclusion and exclusion criteria. These steps were carried out by one reviewer, and 10% of the titles and abstracts evaluated were independently re-evaluated by a second reviewer. The data extraction from the selected documents was carried out by a reviewer. The extracted data were analyzed and presented in the form of a narrative synthesis for each care pathway identified. Given the rapid nature of the work and the type of review conducted, the methodological quality of the selected documents was not assessed. In addition, the consistency of the study results, the number of studies and their perceived quality, the biases raised, and the statistical analyses of the metaanalyses were taken into account when drawing up the findings concerning care pathways and virtual care modalities that support or optimize clinical practices in specialty medicine.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/fileadmin/doc/INESSS/Rapports/OrganisationsSoins/INESSS_Soins_virtuels_Pediatrie_EC.pdf

Year Published: 2023

URL for published report: https://www.inesss.qc.ca/fileadmin/doc/INESSS/Rapports/OrganisationsSoins/INESSS_Soins_virtuels_Pediatrie_EC.pdf

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)