Telemedicine Reduces Absence Resulting From Illness in Urban Child Care: Evaluation of an Innovation

Abstract

Background. Common acute illness challenges everyone involved in child care. Impoverished inner-city families, whose children are most burdened by morbidity and whose reliance on child care is most important, are those least equipped to deal with this challenge. Objective. To assess the impact of telemedicine on absence from child care due to illness (ADI). Design/Methods. A before-and-after design with historical and concurrent controls was used to study ADI in 5 inner-city child care centers in Rochester, New York, between January 1, 2001, and June 30, 2003. Enrollment averaged 138 children per center, of whom Medicaid covered 66%. Center 5 provided only concurrent controls. Telemedicine service began in the first 4 centers in a staggered fashion starting in May 2001. Baseline data on ADI before availability of telemedicine were collected in each center for a minimum of 18 weeks. The telemedicine model for diagnosis and treatment of common acute problems involved both real-time and store-and-forward information exchange between a child and telemedicine assistant in child care and an office-based telemedicine clinician. Devices used were an all-purpose digital camera (with attachments designed to facilitate capture of ear, nose, throat, skin, and eye images) and an electronic stethoscope. ADI indexed illness that had interrupted care and education for children and burdened both parents and the community with work loss and health care-related costs. Detailed attendance records and staff and parent interviews provided data. The total number of days of attendance expected from all registered children over the course of a week (total child-days) served as the denominator in calculating rates for ADI. The center-week served as the primary unit of analysis. This study is descriptive in character; statistics are not inferential but instead serve to summarize observations. Results. For the 400 weeks of valid observations contributed by the 5 centers, the mean ADI was 6.41 absences per 100 child-days per week. In bivariate analysis, predictors of ADI were children's mean age, child care center, proportion of children covered by Medicaid, season of the year, and availability of telemedicine. ADI during weeks with telemedicine (4.07 absences per 100 child-days) was less than half that during weeks without telemedicine (8.78 absences per 100 child-days). After adjusting for potentially confounding variables using the generalized estimating equations method, telemedicine remained the strongest predictor of ADI. A 63% reduction in ADI was attributable to telemedicine, an effect similar to the 59% variation in ADI with season of the year. During the 201 total weeks that telemedicine services were available, 940 telemedicine encounters occurred. Telemedicine clinicians for these 940 encounters recommended exclusion from child care for 7.0% and in-person visits for 2.8% of the children. In surveys, parents indicated that 91.2% of telemedicine contacts allowed them to stay at work and that 93.8% of problems managed by telemedicine would otherwise have led to an office or emergency department visit. Conclusions. Telemedicine holds substantial potential to reduce the impact of illness on health and education of children, on time lost from work in parents, and on absenteeism in the economy.