Cystic fibrosis

The great debate: can telemedicine reduce infections in CF?


Telehealth approaches to patients with cystic fibrosis (CF) may not just be a solution to the tyranny of distance in a big country but can also help minimise infections, an Australian paediatric respiratory physician argues.

In an ATS 2018 debate about whether routine visits to the CF clinic should be reduced due to the increased risk of infection, Professor Claire Wainwright said yes – although new models of care required more research.

Professor Wainwright, from the University of Queensland’s Child Health Research Centre, said there was certainly an increasing problem with infections in CF – including MRSA rates of up to 30%, P. aeruginosa rates of up to 60% and Nontuberculous Mycobacteria (NTM) at about 13%.

And there was plenty of evidence from the UK, US, Europe and Australia that CF clinics were a possible source of infection.

For example, a 2013 Australian study showed 62% of CF patients across a number of centres and wide geography had at least one shared strain of P. aeruginosa.

And more recently, a whole genome analysis of isolates from more than 500 patients had shown evidence of clustering, suggesting patient-to-patient transmission.

Unfortunately infection control measures may not provide adequate protection, said Professor Wainwright. Measures such as the ‘6-foot rule’ [1.8 m] may not be sufficient when research – previously reported here in the limbic – was showing cough aerosols could be found at 4 metres.

“Infection control measures may need to be updated but at the moment the evidence for whether those cough aerosols are infectious is not really known. We don’t really know what the infectious dose is,” she told the limbic.

“What we can say is that there are potentially respirable particles that are viable that remain airborne and we don’t yet know the consequence of that. There are now ventilation systems and we can do modelling, in healthcare environments to see if ventilation strategies can improve that and we can also maybe look at other options including telemedicine.”

Professor Wainwright said there was evidence that telemedicine could reduce hospital admissions in both COPD and chronic heart failure and also reduce mortality in heart failure.

However while there was potential, she conceded there was not yet any good evidence for telehealth in CF.

She said Queensland did a lot of telehealth and outreach because of the geography but it also had other potential benefits for patients such as reducing time away from school or work and saving travel costs.

“It’s quite time consuming for the healthcare team and it also needs be properly resourced from a healthcare perspective, that’s important as well. The way we use it is in the multidisciplinary setting. We might bring a nurse and a doctor and a physiotherapist one after another to see a patient in a remote setting. We won’t all be sitting there together necessarily but we will go one after another to see that patient in their home or in another setting.”

“And that can be helpful and certainly means that patients don’t have to fly down…it’s very useful.”

Professor Wainwright added that there were now many studies looking to see if different aspects of care such as dietetic consultations could provided through telehealth. Some people were trialing portable equipment such as spirometry or smartphone apps.

“It probably depends on the situation and what you are trying to achieve. There are lots of different telehealth interventions.”

“But exactly how to do it for each individual is not terribly easy to define because there are individual requirements. Some patients might need more physiotherapy or more dietetic review. You have to individualise these things but overall there are lots of different telemedicine interventions that are being done.”

“I think we do need to know more about it and we do need to know what kind of outcomes we are going to get.”

Her opponent in the debate Dr Greg Sawicki, director of the Cystic Fibrosis Center at Boston Children’s Hospital, said the benefits of routine visits to the CF clinic far outweighed the small risk of infection.

“Telemedicine is a future for everybody but to augment not to replace routine care. We need a middle ground,” he said.

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