Klarman Molly B, Chi Xiaofei, Cajusma Youseline, Flaherty Katelyn E, Beausejour Jude Ronald, Exantus Lerby, Beau de Rochars Valery Madsen, Baril Chantale, Becker Torben K, Gurka Matthew J, Nelson Eric J
Department of Pediatrics, University of Florida, Gainesville, Florida.
Department of Environmental and Global Health, University of Florida, Gainesville, Florida.
Am J Trop Med Hyg. 2025 Jun 24. doi: 10.4269/ajtmh.24-0846.
Early access to health care is essential to avert morbidity and mortality. A telemedicine and medication delivery service (TMDS) is an innovative solution to address this need; however, pathways to scalability are unclear. We sought to evaluate a scalable pediatric TMDS. A TMDS in Haiti was configured for scalability by triaging severe cases to hospital-level care, nonsevere cases with higher clinical uncertainty to in-person examinations at households, and nonsevere cases with low clinical uncertainty to medication delivery alone. This design was evaluated in a prospective cohort study conducted among pediatric patients 10 years old or younger. Clinical and operational metrics were compared with a formative reference study in which all nonsevere patients received an in-person examination. The primary outcomes were rates of clinical improvement/recovery and in-person care seeking at 10 days. In total, 1,043 cases were enrolled in the scalable TMDS mode, and 19% (190) of nonsevere cases received an in-person examination; 382 cases were enrolled in the reference study, and 94% (338) of nonsevere cases received an in-person examination. At 10 days, rates of improvement were similar for the scalable and reference modes. Rates of participants who sought follow-up care were 15% in the scalable mode and 24% in the reference mode. In the context of a 5-fold reduction of in-person examinations, participants in the scalable mode had noninferior rates of improvement at 10 days. These findings highlight an innovative and now scalable solution to improve early access to health care without compromising safety.
早期获得医疗保健对于避免发病和死亡至关重要。远程医疗和药物配送服务（TMDS）是满足这一需求的创新解决方案；然而，扩大规模的途径尚不清楚。我们试图评估一种可扩展的儿科TMDS。海地的一个TMDS通过将重症病例分诊到医院级护理、将临床不确定性较高的非重症病例分诊到上门体检、将临床不确定性较低的非重症病例仅分诊到药物配送来实现可扩展性配置。在一项针对10岁及以下儿科患者的前瞻性队列研究中对这种设计进行了评估。将临床和操作指标与一项形成性参考研究进行了比较，在该参考研究中，所有非重症患者都接受了上门体检。主要结局是10天时的临床改善/康复率和寻求上门护理率。总共1043例病例以可扩展TMDS模式入组，19%（190例）的非重症病例接受了上门体检；382例病例入组参考研究，94%（338例）的非重症病例接受了上门体检。在10天时，可扩展模式和参考模式的改善率相似。在可扩展模式下寻求后续护理的参与者比例为15%，在参考模式下为24%。在上门体检减少5倍的情况下，可扩展模式下的参与者在10天时的改善率并不逊色。这些发现凸显了一种创新且目前可扩展的解决方案，可在不影响安全性的情况下改善早期获得医疗保健的机会。
